The New Gastroenterologist

Congratulations! You have matched in a competitive medical subspecialty or you have secured your first faculty position. But what do you do now? Success in your early career – as a new fellow or a new attending – requires both hard work and perseverance. We present our top 12 tips for how to be successful as you transition into your new position.

Tip #1: Be kind to yourself

As you transition from medical resident to GI fellow or from GI fellow to first-time attending, it is important to recognize that you are going through a major career transition (not as major as fourth year to intern, but probably a close second). First and foremost, remember to be kind to yourself and set reasonable expectations. You need to allow yourself time to transition to a new role which may also be in a new city or state. Take care of yourself – don’t forget to exercise, eat well, and sleep. You are in the long game now. Work to get yourself in a routine that is sustainable. Block out time to exercise, explore your new city, meal plan, and pursue your interests outside of medicine.

Tip #2: Set up for success

Since you are going through this major life/career transition, it is really helpful if you can set yourself up for success by having some projects that are easily completed during this challenging time so that you can demonstrate success. If you have projects in different stages of development, you will always have something you can work on when some projects are delayed for reasons outside of your control. In particular, it is great to have a few papers ready to go during late fellowship so they are published during your first year as an academic attending! This will allow you to continue your research trajectory as you learn the ropes of your new position.

Tip #3: Ask for help

It turns out you cannot do everything on your own! Make sure you are getting help professionally and personally so that you are set up for success. It’s okay to feel overwhelmed or confused; we all do at some point or another. Fellowship and early academic faculty years are stressful and nobody expects you to do it alone. Chances are your mentors or cofellows have had similar struggles, and in opening up, this dialogue may help you both.
 

Tip #4: Write out your 5-year plan

You need to know where you are going before you can figure out how to get there. Take some time for “soul searching”: Think about where you would like to be in 5 years and work backward (along with help from your mentors; see Tip #5) to determine how best to get there. If you think a career in academia might be for you, it’s never too soon to start networking and involving yourself in research. If a specific institution or clinical position draws your attention, check out the current faculty. You can use their CVs as a roadmap of types of experiences and honors that should be on your radar throughout these 5 years. Remember that your 5-year plan is not written in stone – this is something that you should re-evaluate as your interests and priorities change throughout your career.
 

Tip #5: Develop your personal ‘Board of Directors’

Instead of trying to find the perfect mentor, we suggest you seek out a personal “Board of Directors” who can serve as your mentoring team. There will never be a single perfect mentor for you and it is likely that you will need separate mentors to help guide you on different aspects of your career. I personally have separate individuals serving as my clinical mentor, my research content mentor, my research methods mentor, my career mentor, and my personal/life mentor. Having multiple mentors allows you to maximize the impact of your different mentors’ strengths across each component of your career. Further, your mentors themselves may have past histories of collaboration that you may then leverage to buoy your own fledgling career. When deciding on who to choose as a mentor, it is important to talk to prior mentees about their experiences with a mentor to help you decide if you may be a good match.
 

Tip #6: Master the art of “Menteering”

Now that you have identified mentors, you need to do your part in nurturing this mentee-mentor relationship. Be an excellent mentee: Show up, stick to a timeline, bring ideas and enthusiasm, and make it easy for your mentor. Your mentors want to see you succeed and sometimes this requires you to help them help you. If you know your own learning style and how you like to interact, have that conversation with your mentor upfront (for example, you may need strict deadlines or you may prefer having more time to develop ideas). Having these conversations before you start a project or a relationship will help set the expectations and ensure effective communication with your mentor. If you find that your mentor is doing something that hinders your progress, such as asking for updates too often or not checking in enough, have a constructive conversation with them about how you feel. Come prepared for meetings with your mentor with an agenda and timeline. Be specific if there is something you need from your mentor and be respectful of their other commitments. For example, if you would like your mentor to review your grant application, let them know the grant deadline and find out when you need to get them a draft so that they will have time to provide meaningful feedback.
 

Tip #7: Identify sponsors

Equally, if not more important than your mentoring team, are sponsors. These are people in positions of power who will promote you and help push your career forward. Sponsors can be people more senior to you, cofellows, or even acquaintances in industry or pharmaceuticals. Your mentor may also be your sponsor, but not always. As early academic faculty, it is important to get your name out there with speaking engagements related to your clinical and research niche, and that is one way a sponsor can help bolster your career.

Tip #8: Develop your personal brand – what is on your T-shirt?

As medicine becomes more and more subspecialized, finding your brand is becoming increasingly important. A brand could be anything from your academic niche to social justice, or even social media utilization. Your brand should encompass what you are naturally excited by within your field. Finding your brand will not only distinguish you from your peers but will also provide you with expertise which you can then offer to your colleagues, near and far. Practice the “elevator pitch” of your personal brand so that you can effectively (and efficiently) describe yourself and your interests when meeting new people and networking.
 

Tip #9: Meet thought leaders in your field

Think of the top five or six most prominent and influential people in your area of clinical or research interest and introduce yourself. This can be done at a national meeting or simply over email, though in person is always best if possible. Although thought leaders are busy, in my experience, if you are persistent, you can always find a few minutes to make an introduction. I’ve shared cab rides just to get a few minutes of someone’s time. In my first few years on faculty, I met with most of the thought leaders in my field; some of these meetings led to fruitful collaborations and important introductions (see tip #7). Meet others at your career level too. They can be great to bounce ideas off, and they will be future leaders in the field. Inviting thought leaders to come to your institution to give talks (in-person or virtually) is another great way to show your interest in their work and also find time to introduce yourself.
 

Tip #10: Apply, apply, apply

Remember that feedback is a gift and the best way to receive feedback is to apply to as many opportunities as you can. Any successful person in GI will have a ‘CV of failures’ far longer than their actual CV documenting their successes. I applied to 8 grants before landing my first one, but I received invaluable feedback and improved my writing skills in the process. Success in fellowship and early faculty takes immense grit – work on building a thick skin and finding the learning opportunity within any outcome.
 

Tip #11: Don’t get sucked into the email abyss

It is easy to fill your time completing low priority, but easy to complete, tasks such as responding to emails. Time management is key and you need to make sure that you dedicate time to more time-consuming tasks – such as writing and developing projects/grants – that have a high reward. Dedicate time on your calendar for high-priority tasks and make sure you don’t open your email during this time. Turn off the email pop-up window and do emails at the end of the day (or whenever you are done writing and thinking). Limiting distractions will help get your creative juices flowing.
 

Tip #12: Don’t always say yes

In fact, don’t ever say yes to a career or research opportunity within the first 24 hours to allow yourself time to weigh the pros and cons of the commitment, to assess the timeline feasibility, and to decide it fits into your 5-year plan. You can say you need to talk to your mentor about it first. If you decide you cannot accept an opportunity, a great way to mitigate that is to simply say “I’d love to, but my mentor says no.” Act as a sponsor to someone else by suggesting a potential colleague who might be interested in the opportunity. As you accept more responsibilities, think about what you might be able to give up to give yourself time to be successful in this new opportunity (and not distract from yourself or your 5-year plan).  
 

Conclusion

Success in research and early academic faculty years takes planning and determination. We hope these tips provide a broad outline for what to think about and how to approach planning your future career. First and foremost, you must put in the time to think about what you really want and what will make you happy in the long run. Academic success is a broad term that each of us defines differently. What does it mean to you? Once you figure that out, make your 5-year plan and run with it!

Dr. Rebello and Dr. Long are with section of gastroenterology at Boston Medical Center and Boston University. They have no conflicts to report.

Congratulations! You have matched in a competitive medical subspecialty or you have secured your first faculty position. But what do you do now? Success in your early career – as a new fellow or a new attending – requires both hard work and perseverance. We present our top 12 tips for how to be successful as you transition into your new position.

Tip #1: Be kind to yourself

As you transition from medical resident to GI fellow or from GI fellow to first-time attending, it is important to recognize that you are going through a major career transition (not as major as fourth year to intern, but probably a close second). First and foremost, remember to be kind to yourself and set reasonable expectations. You need to allow yourself time to transition to a new role which may also be in a new city or state. Take care of yourself – don’t forget to exercise, eat well, and sleep. You are in the long game now. Work to get yourself in a routine that is sustainable. Block out time to exercise, explore your new city, meal plan, and pursue your interests outside of medicine.

Tip #2: Set up for success

Since you are going through this major life/career transition, it is really helpful if you can set yourself up for success by having some projects that are easily completed during this challenging time so that you can demonstrate success. If you have projects in different stages of development, you will always have something you can work on when some projects are delayed for reasons outside of your control. In particular, it is great to have a few papers ready to go during late fellowship so they are published during your first year as an academic attending! This will allow you to continue your research trajectory as you learn the ropes of your new position.

Tip #3: Ask for help

It turns out you cannot do everything on your own! Make sure you are getting help professionally and personally so that you are set up for success. It’s okay to feel overwhelmed or confused; we all do at some point or another. Fellowship and early academic faculty years are stressful and nobody expects you to do it alone. Chances are your mentors or cofellows have had similar struggles, and in opening up, this dialogue may help you both.
 

Tip #4: Write out your 5-year plan

You need to know where you are going before you can figure out how to get there. Take some time for “soul searching”: Think about where you would like to be in 5 years and work backward (along with help from your mentors; see Tip #5) to determine how best to get there. If you think a career in academia might be for you, it’s never too soon to start networking and involving yourself in research. If a specific institution or clinical position draws your attention, check out the current faculty. You can use their CVs as a roadmap of types of experiences and honors that should be on your radar throughout these 5 years. Remember that your 5-year plan is not written in stone – this is something that you should re-evaluate as your interests and priorities change throughout your career.
 

Tip #5: Develop your personal ‘Board of Directors’

Instead of trying to find the perfect mentor, we suggest you seek out a personal “Board of Directors” who can serve as your mentoring team. There will never be a single perfect mentor for you and it is likely that you will need separate mentors to help guide you on different aspects of your career. I personally have separate individuals serving as my clinical mentor, my research content mentor, my research methods mentor, my career mentor, and my personal/life mentor. Having multiple mentors allows you to maximize the impact of your different mentors’ strengths across each component of your career. Further, your mentors themselves may have past histories of collaboration that you may then leverage to buoy your own fledgling career. When deciding on who to choose as a mentor, it is important to talk to prior mentees about their experiences with a mentor to help you decide if you may be a good match.
 

Tip #6: Master the art of “Menteering”

Now that you have identified mentors, you need to do your part in nurturing this mentee-mentor relationship. Be an excellent mentee: Show up, stick to a timeline, bring ideas and enthusiasm, and make it easy for your mentor. Your mentors want to see you succeed and sometimes this requires you to help them help you. If you know your own learning style and how you like to interact, have that conversation with your mentor upfront (for example, you may need strict deadlines or you may prefer having more time to develop ideas). Having these conversations before you start a project or a relationship will help set the expectations and ensure effective communication with your mentor. If you find that your mentor is doing something that hinders your progress, such as asking for updates too often or not checking in enough, have a constructive conversation with them about how you feel. Come prepared for meetings with your mentor with an agenda and timeline. Be specific if there is something you need from your mentor and be respectful of their other commitments. For example, if you would like your mentor to review your grant application, let them know the grant deadline and find out when you need to get them a draft so that they will have time to provide meaningful feedback.
 

Tip #7: Identify sponsors

Equally, if not more important than your mentoring team, are sponsors. These are people in positions of power who will promote you and help push your career forward. Sponsors can be people more senior to you, cofellows, or even acquaintances in industry or pharmaceuticals. Your mentor may also be your sponsor, but not always. As early academic faculty, it is important to get your name out there with speaking engagements related to your clinical and research niche, and that is one way a sponsor can help bolster your career.

Tip #8: Develop your personal brand – what is on your T-shirt?

As medicine becomes more and more subspecialized, finding your brand is becoming increasingly important. A brand could be anything from your academic niche to social justice, or even social media utilization. Your brand should encompass what you are naturally excited by within your field. Finding your brand will not only distinguish you from your peers but will also provide you with expertise which you can then offer to your colleagues, near and far. Practice the “elevator pitch” of your personal brand so that you can effectively (and efficiently) describe yourself and your interests when meeting new people and networking.
 

Tip #9: Meet thought leaders in your field

Think of the top five or six most prominent and influential people in your area of clinical or research interest and introduce yourself. This can be done at a national meeting or simply over email, though in person is always best if possible. Although thought leaders are busy, in my experience, if you are persistent, you can always find a few minutes to make an introduction. I’ve shared cab rides just to get a few minutes of someone’s time. In my first few years on faculty, I met with most of the thought leaders in my field; some of these meetings led to fruitful collaborations and important introductions (see tip #7). Meet others at your career level too. They can be great to bounce ideas off, and they will be future leaders in the field. Inviting thought leaders to come to your institution to give talks (in-person or virtually) is another great way to show your interest in their work and also find time to introduce yourself.
 

Tip #10: Apply, apply, apply

Remember that feedback is a gift and the best way to receive feedback is to apply to as many opportunities as you can. Any successful person in GI will have a ‘CV of failures’ far longer than their actual CV documenting their successes. I applied to 8 grants before landing my first one, but I received invaluable feedback and improved my writing skills in the process. Success in fellowship and early faculty takes immense grit – work on building a thick skin and finding the learning opportunity within any outcome.
 

Tip #11: Don’t get sucked into the email abyss

It is easy to fill your time completing low priority, but easy to complete, tasks such as responding to emails. Time management is key and you need to make sure that you dedicate time to more time-consuming tasks – such as writing and developing projects/grants – that have a high reward. Dedicate time on your calendar for high-priority tasks and make sure you don’t open your email during this time. Turn off the email pop-up window and do emails at the end of the day (or whenever you are done writing and thinking). Limiting distractions will help get your creative juices flowing.
 

Tip #12: Don’t always say yes

In fact, don’t ever say yes to a career or research opportunity within the first 24 hours to allow yourself time to weigh the pros and cons of the commitment, to assess the timeline feasibility, and to decide it fits into your 5-year plan. You can say you need to talk to your mentor about it first. If you decide you cannot accept an opportunity, a great way to mitigate that is to simply say “I’d love to, but my mentor says no.” Act as a sponsor to someone else by suggesting a potential colleague who might be interested in the opportunity. As you accept more responsibilities, think about what you might be able to give up to give yourself time to be successful in this new opportunity (and not distract from yourself or your 5-year plan).  
 

Conclusion

Success in research and early academic faculty years takes planning and determination. We hope these tips provide a broad outline for what to think about and how to approach planning your future career. First and foremost, you must put in the time to think about what you really want and what will make you happy in the long run. Academic success is a broad term that each of us defines differently. What does it mean to you? Once you figure that out, make your 5-year plan and run with it!

Dr. Rebello and Dr. Long are with section of gastroenterology at Boston Medical Center and Boston University. They have no conflicts to report.

Congratulations! You have matched in a competitive medical subspecialty or you have secured your first faculty position. But what do you do now? Success in your early career – as a new fellow or a new attending – requires both hard work and perseverance. We present our top 12 tips for how to be successful as you transition into your new position.

Tip #1: Be kind to yourself

As you transition from medical resident to GI fellow or from GI fellow to first-time attending, it is important to recognize that you are going through a major career transition (not as major as fourth year to intern, but probably a close second). First and foremost, remember to be kind to yourself and set reasonable expectations. You need to allow yourself time to transition to a new role which may also be in a new city or state. Take care of yourself – don’t forget to exercise, eat well, and sleep. You are in the long game now. Work to get yourself in a routine that is sustainable. Block out time to exercise, explore your new city, meal plan, and pursue your interests outside of medicine.

Tip #2: Set up for success

Since you are going through this major life/career transition, it is really helpful if you can set yourself up for success by having some projects that are easily completed during this challenging time so that you can demonstrate success. If you have projects in different stages of development, you will always have something you can work on when some projects are delayed for reasons outside of your control. In particular, it is great to have a few papers ready to go during late fellowship so they are published during your first year as an academic attending! This will allow you to continue your research trajectory as you learn the ropes of your new position.

Tip #3: Ask for help

It turns out you cannot do everything on your own! Make sure you are getting help professionally and personally so that you are set up for success. It’s okay to feel overwhelmed or confused; we all do at some point or another. Fellowship and early academic faculty years are stressful and nobody expects you to do it alone. Chances are your mentors or cofellows have had similar struggles, and in opening up, this dialogue may help you both.
 

Tip #4: Write out your 5-year plan

You need to know where you are going before you can figure out how to get there. Take some time for “soul searching”: Think about where you would like to be in 5 years and work backward (along with help from your mentors; see Tip #5) to determine how best to get there. If you think a career in academia might be for you, it’s never too soon to start networking and involving yourself in research. If a specific institution or clinical position draws your attention, check out the current faculty. You can use their CVs as a roadmap of types of experiences and honors that should be on your radar throughout these 5 years. Remember that your 5-year plan is not written in stone – this is something that you should re-evaluate as your interests and priorities change throughout your career.
 

Tip #5: Develop your personal ‘Board of Directors’

Instead of trying to find the perfect mentor, we suggest you seek out a personal “Board of Directors” who can serve as your mentoring team. There will never be a single perfect mentor for you and it is likely that you will need separate mentors to help guide you on different aspects of your career. I personally have separate individuals serving as my clinical mentor, my research content mentor, my research methods mentor, my career mentor, and my personal/life mentor. Having multiple mentors allows you to maximize the impact of your different mentors’ strengths across each component of your career. Further, your mentors themselves may have past histories of collaboration that you may then leverage to buoy your own fledgling career. When deciding on who to choose as a mentor, it is important to talk to prior mentees about their experiences with a mentor to help you decide if you may be a good match.
 

Tip #6: Master the art of “Menteering”

Now that you have identified mentors, you need to do your part in nurturing this mentee-mentor relationship. Be an excellent mentee: Show up, stick to a timeline, bring ideas and enthusiasm, and make it easy for your mentor. Your mentors want to see you succeed and sometimes this requires you to help them help you. If you know your own learning style and how you like to interact, have that conversation with your mentor upfront (for example, you may need strict deadlines or you may prefer having more time to develop ideas). Having these conversations before you start a project or a relationship will help set the expectations and ensure effective communication with your mentor. If you find that your mentor is doing something that hinders your progress, such as asking for updates too often or not checking in enough, have a constructive conversation with them about how you feel. Come prepared for meetings with your mentor with an agenda and timeline. Be specific if there is something you need from your mentor and be respectful of their other commitments. For example, if you would like your mentor to review your grant application, let them know the grant deadline and find out when you need to get them a draft so that they will have time to provide meaningful feedback.
 

Tip #7: Identify sponsors

Equally, if not more important than your mentoring team, are sponsors. These are people in positions of power who will promote you and help push your career forward. Sponsors can be people more senior to you, cofellows, or even acquaintances in industry or pharmaceuticals. Your mentor may also be your sponsor, but not always. As early academic faculty, it is important to get your name out there with speaking engagements related to your clinical and research niche, and that is one way a sponsor can help bolster your career.

Tip #8: Develop your personal brand – what is on your T-shirt?

As medicine becomes more and more subspecialized, finding your brand is becoming increasingly important. A brand could be anything from your academic niche to social justice, or even social media utilization. Your brand should encompass what you are naturally excited by within your field. Finding your brand will not only distinguish you from your peers but will also provide you with expertise which you can then offer to your colleagues, near and far. Practice the “elevator pitch” of your personal brand so that you can effectively (and efficiently) describe yourself and your interests when meeting new people and networking.
 

Tip #9: Meet thought leaders in your field

Think of the top five or six most prominent and influential people in your area of clinical or research interest and introduce yourself. This can be done at a national meeting or simply over email, though in person is always best if possible. Although thought leaders are busy, in my experience, if you are persistent, you can always find a few minutes to make an introduction. I’ve shared cab rides just to get a few minutes of someone’s time. In my first few years on faculty, I met with most of the thought leaders in my field; some of these meetings led to fruitful collaborations and important introductions (see tip #7). Meet others at your career level too. They can be great to bounce ideas off, and they will be future leaders in the field. Inviting thought leaders to come to your institution to give talks (in-person or virtually) is another great way to show your interest in their work and also find time to introduce yourself.
 

Tip #10: Apply, apply, apply

Remember that feedback is a gift and the best way to receive feedback is to apply to as many opportunities as you can. Any successful person in GI will have a ‘CV of failures’ far longer than their actual CV documenting their successes. I applied to 8 grants before landing my first one, but I received invaluable feedback and improved my writing skills in the process. Success in fellowship and early faculty takes immense grit – work on building a thick skin and finding the learning opportunity within any outcome.
 

Tip #11: Don’t get sucked into the email abyss

It is easy to fill your time completing low priority, but easy to complete, tasks such as responding to emails. Time management is key and you need to make sure that you dedicate time to more time-consuming tasks – such as writing and developing projects/grants – that have a high reward. Dedicate time on your calendar for high-priority tasks and make sure you don’t open your email during this time. Turn off the email pop-up window and do emails at the end of the day (or whenever you are done writing and thinking). Limiting distractions will help get your creative juices flowing.
 

Tip #12: Don’t always say yes

In fact, don’t ever say yes to a career or research opportunity within the first 24 hours to allow yourself time to weigh the pros and cons of the commitment, to assess the timeline feasibility, and to decide it fits into your 5-year plan. You can say you need to talk to your mentor about it first. If you decide you cannot accept an opportunity, a great way to mitigate that is to simply say “I’d love to, but my mentor says no.” Act as a sponsor to someone else by suggesting a potential colleague who might be interested in the opportunity. As you accept more responsibilities, think about what you might be able to give up to give yourself time to be successful in this new opportunity (and not distract from yourself or your 5-year plan).  
 

Conclusion

Success in research and early academic faculty years takes planning and determination. We hope these tips provide a broad outline for what to think about and how to approach planning your future career. First and foremost, you must put in the time to think about what you really want and what will make you happy in the long run. Academic success is a broad term that each of us defines differently. What does it mean to you? Once you figure that out, make your 5-year plan and run with it!

Dr. Rebello and Dr. Long are with section of gastroenterology at Boston Medical Center and Boston University. They have no conflicts to report.

It is not an exaggeration to say that everything in my gastroenterology practice changed in response to COVID-19.

Due to the overwhelming surge that Massachusetts saw in the early days of the pandemic, the Department of Public Health issued a moratorium on elective procedures in mid-March of 2020, for both hospitals and ambulatory surgery centers. The moratorium included colorectal cancer (CRC) screenings and other procedures that make up a significant portion of the services we provide to our community. Greater Boston Gastroenterology treats patients in and around the area of Framingham, Mass. – not too far outside of Boston. In our practice, we have seven physicians and three nurse practitioners, with one main office and two satellite offices. By national standards, our practice would be considered small, but it is on the larger side of independent GI physician practices in the commonwealth.

Nationally, moratoria on elective procedures led to one of the steepest drop-offs in screenings for cancers, including colorectal cancer. In late summer of 2020, it was estimated that CRC screenings dropped by 86 percent. Two-thirds of independent GI practices saw a significant decline in patient volume, and many believe that they may not get it back.

However, I’m an optimist in this situation, and I believe that as life gets more normal, people will get back to screenings. With the recommendation by the U.S. Preventative Services Task Force that CRC screening should begin at age 45, I expect that there will be an additional increase in screening soon.
 

Pivoting and developing a reopening plan

Almost immediately after the Department of Public Health issued the moratorium, Greater Boston Gastroenterology began putting together a reopening plan that would allow us to continue treating some patients and prepare for a surge once restrictions were lifted.

Part of our plan was to stay informed by talking with other practices about what they were doing and to stay abreast of policy changes at the local, state, and federal levels.

We also needed to keep our patients informed to alleviate safety concerns. Just prior to our reopening, we developed videos of the precautions that we were taking in all our facilities to assure our patients that we were doing everything possible to keep them safe. We also put information on our website through every stage of reopening so patients could know what to expect at their visits.

Helping our staff feel safe as they returned to work was also an important focus of our reopening plan. We prepared for our eventual reopening by installing safety measures such as plexiglass barriers and HEPA filter machines for our common areas and exam rooms. We also procured access to rapid turnaround polymerase chain reaction (PCR) testing that allowed us to regularly test all patients seeking elective procedures. Additionally, we invested in point-of-care antigen tests for the office, and we regularly test all our patient-facing staff.

We had corralled enough personal protective equipment to keep our office infusion services operating with our nurses and patients feeling safe. The preparation allowed us to resume in-person visits almost immediately after the Department of Public Health allowed us to reopen.

Once we reopened, we concentrated on in-office visits for patients who were under 65 and at lower risk for COVID-19, while focusing our telemedicine efforts on patients who were older and at higher risk. We’re now back to seeing all patients who want to have in-office visits and are actually above par for our visits. The number of procedures we have performed in the last 3 months is similar to the 3 months before the pandemic.

During the pandemic, Massachusetts had the best conversion to telehealth in the nation, and it worked well for patients and providers. The key was to use several telehealth apps, as using only one may not work for everyone. Having several options made it likely that we would be able to do complete visits and connect with patients. When we needed to, we switched to telephone visits.

All the physicians and staff in our practice are telemedicine enthusiasts, and it will remain a significant part of our practices as long as Medicare, the state health plans, and commercial payers remain supportive.
 

Planning for a surge in screenings

There may be a surge in screenings once more people are vaccinated and comfortable getting back into the office, and we’re planning for this as well. We’ve recruited new physicians and have expanded our available hours for procedures at our ambulatory surgery centers (ASCs). Surprisingly, we have found that there is a lot of interest from physicians for weekend shifts at the ASC, and we now have a physician waiting list for Saturday procedure time.

With the new lower age for recommended screening, there will be a lag with primary care physicians referring their younger patients. This may provide some time to prepare for an increase in screenings resulting from this new policy.

Another strategy that has worked well for us is to train and develop our advanced practitioners into nonphysician experts in GI and liver disease. Greater Boston Gastroenterology has used this strategy since its founding, and we think our most experienced nurse practitioners could rival any office-based gastroenterologist in their acumen and capabilities.

Over the last 3 years we have transitioned our nonphysician practitioners into the inpatient setting. As a result, consults are completed earlier in the day, and we are better able to help coordinate inpatient procedure scheduling, discharge planning, and outpatient follow-up.

The time we spend on training is worth it. It improves customer service, allows us to book appointments with shorter notice, and overall has a positive effect on our bottom line. Utilizing our advanced providers in this capacity will help us manage any volume increases we see in the near future. In addition, most patients in our community are used to seeing advanced providers in their physician’s office, so the acceptance among our patients is high.
 

Being flexible and favoring strategic planning

Overall, I think the greatest thing we learned during the pandemic is that we need to be flexible. It was a helpful reminder that, in medicine, things are constantly changing. I remember when passing the GI boards seemed like my final step, but everyone comes to realize it is just the first step in the journey.

As an early-career physician, you should remember the hard work that helped you get to medical school, land a good residency, stand out to get a fellowship, and master your specialty. Harness that personal drive and energy and keep moving forward. Remember that your first job is unlikely to be your last. Try not to see your choices as either/or – either academic or private practice, hospital-employed or self-employed. The boundaries are blurring. We have long careers and face myriad opportunities for professional advancement.

Be patient. Some goals take time to achieve. At each stage be prepared to work hard, use your time wisely, and try not to lose sight of maximizing your professional happiness.
 

Dr. Dickstein is a practicing gastroenterologist at Greater Boston Gastroenterology in Framingham, Mass., and serves on the executive committee of the Digestive Health Physicians Association. He has no conflicts to declare.

It is not an exaggeration to say that everything in my gastroenterology practice changed in response to COVID-19.

Due to the overwhelming surge that Massachusetts saw in the early days of the pandemic, the Department of Public Health issued a moratorium on elective procedures in mid-March of 2020, for both hospitals and ambulatory surgery centers. The moratorium included colorectal cancer (CRC) screenings and other procedures that make up a significant portion of the services we provide to our community. Greater Boston Gastroenterology treats patients in and around the area of Framingham, Mass. – not too far outside of Boston. In our practice, we have seven physicians and three nurse practitioners, with one main office and two satellite offices. By national standards, our practice would be considered small, but it is on the larger side of independent GI physician practices in the commonwealth.

Nationally, moratoria on elective procedures led to one of the steepest drop-offs in screenings for cancers, including colorectal cancer. In late summer of 2020, it was estimated that CRC screenings dropped by 86 percent. Two-thirds of independent GI practices saw a significant decline in patient volume, and many believe that they may not get it back.

However, I’m an optimist in this situation, and I believe that as life gets more normal, people will get back to screenings. With the recommendation by the U.S. Preventative Services Task Force that CRC screening should begin at age 45, I expect that there will be an additional increase in screening soon.
 

Pivoting and developing a reopening plan

Almost immediately after the Department of Public Health issued the moratorium, Greater Boston Gastroenterology began putting together a reopening plan that would allow us to continue treating some patients and prepare for a surge once restrictions were lifted.

Part of our plan was to stay informed by talking with other practices about what they were doing and to stay abreast of policy changes at the local, state, and federal levels.

We also needed to keep our patients informed to alleviate safety concerns. Just prior to our reopening, we developed videos of the precautions that we were taking in all our facilities to assure our patients that we were doing everything possible to keep them safe. We also put information on our website through every stage of reopening so patients could know what to expect at their visits.

Helping our staff feel safe as they returned to work was also an important focus of our reopening plan. We prepared for our eventual reopening by installing safety measures such as plexiglass barriers and HEPA filter machines for our common areas and exam rooms. We also procured access to rapid turnaround polymerase chain reaction (PCR) testing that allowed us to regularly test all patients seeking elective procedures. Additionally, we invested in point-of-care antigen tests for the office, and we regularly test all our patient-facing staff.

We had corralled enough personal protective equipment to keep our office infusion services operating with our nurses and patients feeling safe. The preparation allowed us to resume in-person visits almost immediately after the Department of Public Health allowed us to reopen.

Once we reopened, we concentrated on in-office visits for patients who were under 65 and at lower risk for COVID-19, while focusing our telemedicine efforts on patients who were older and at higher risk. We’re now back to seeing all patients who want to have in-office visits and are actually above par for our visits. The number of procedures we have performed in the last 3 months is similar to the 3 months before the pandemic.

During the pandemic, Massachusetts had the best conversion to telehealth in the nation, and it worked well for patients and providers. The key was to use several telehealth apps, as using only one may not work for everyone. Having several options made it likely that we would be able to do complete visits and connect with patients. When we needed to, we switched to telephone visits.

All the physicians and staff in our practice are telemedicine enthusiasts, and it will remain a significant part of our practices as long as Medicare, the state health plans, and commercial payers remain supportive.
 

Planning for a surge in screenings

There may be a surge in screenings once more people are vaccinated and comfortable getting back into the office, and we’re planning for this as well. We’ve recruited new physicians and have expanded our available hours for procedures at our ambulatory surgery centers (ASCs). Surprisingly, we have found that there is a lot of interest from physicians for weekend shifts at the ASC, and we now have a physician waiting list for Saturday procedure time.

With the new lower age for recommended screening, there will be a lag with primary care physicians referring their younger patients. This may provide some time to prepare for an increase in screenings resulting from this new policy.

Another strategy that has worked well for us is to train and develop our advanced practitioners into nonphysician experts in GI and liver disease. Greater Boston Gastroenterology has used this strategy since its founding, and we think our most experienced nurse practitioners could rival any office-based gastroenterologist in their acumen and capabilities.

Over the last 3 years we have transitioned our nonphysician practitioners into the inpatient setting. As a result, consults are completed earlier in the day, and we are better able to help coordinate inpatient procedure scheduling, discharge planning, and outpatient follow-up.

The time we spend on training is worth it. It improves customer service, allows us to book appointments with shorter notice, and overall has a positive effect on our bottom line. Utilizing our advanced providers in this capacity will help us manage any volume increases we see in the near future. In addition, most patients in our community are used to seeing advanced providers in their physician’s office, so the acceptance among our patients is high.
 

Being flexible and favoring strategic planning

Overall, I think the greatest thing we learned during the pandemic is that we need to be flexible. It was a helpful reminder that, in medicine, things are constantly changing. I remember when passing the GI boards seemed like my final step, but everyone comes to realize it is just the first step in the journey.

As an early-career physician, you should remember the hard work that helped you get to medical school, land a good residency, stand out to get a fellowship, and master your specialty. Harness that personal drive and energy and keep moving forward. Remember that your first job is unlikely to be your last. Try not to see your choices as either/or – either academic or private practice, hospital-employed or self-employed. The boundaries are blurring. We have long careers and face myriad opportunities for professional advancement.

Be patient. Some goals take time to achieve. At each stage be prepared to work hard, use your time wisely, and try not to lose sight of maximizing your professional happiness.
 

Dr. Dickstein is a practicing gastroenterologist at Greater Boston Gastroenterology in Framingham, Mass., and serves on the executive committee of the Digestive Health Physicians Association. He has no conflicts to declare.

It is not an exaggeration to say that everything in my gastroenterology practice changed in response to COVID-19.

Due to the overwhelming surge that Massachusetts saw in the early days of the pandemic, the Department of Public Health issued a moratorium on elective procedures in mid-March of 2020, for both hospitals and ambulatory surgery centers. The moratorium included colorectal cancer (CRC) screenings and other procedures that make up a significant portion of the services we provide to our community. Greater Boston Gastroenterology treats patients in and around the area of Framingham, Mass. – not too far outside of Boston. In our practice, we have seven physicians and three nurse practitioners, with one main office and two satellite offices. By national standards, our practice would be considered small, but it is on the larger side of independent GI physician practices in the commonwealth.

Nationally, moratoria on elective procedures led to one of the steepest drop-offs in screenings for cancers, including colorectal cancer. In late summer of 2020, it was estimated that CRC screenings dropped by 86 percent. Two-thirds of independent GI practices saw a significant decline in patient volume, and many believe that they may not get it back.

However, I’m an optimist in this situation, and I believe that as life gets more normal, people will get back to screenings. With the recommendation by the U.S. Preventative Services Task Force that CRC screening should begin at age 45, I expect that there will be an additional increase in screening soon.
 

Pivoting and developing a reopening plan

Almost immediately after the Department of Public Health issued the moratorium, Greater Boston Gastroenterology began putting together a reopening plan that would allow us to continue treating some patients and prepare for a surge once restrictions were lifted.

Part of our plan was to stay informed by talking with other practices about what they were doing and to stay abreast of policy changes at the local, state, and federal levels.

We also needed to keep our patients informed to alleviate safety concerns. Just prior to our reopening, we developed videos of the precautions that we were taking in all our facilities to assure our patients that we were doing everything possible to keep them safe. We also put information on our website through every stage of reopening so patients could know what to expect at their visits.

Helping our staff feel safe as they returned to work was also an important focus of our reopening plan. We prepared for our eventual reopening by installing safety measures such as plexiglass barriers and HEPA filter machines for our common areas and exam rooms. We also procured access to rapid turnaround polymerase chain reaction (PCR) testing that allowed us to regularly test all patients seeking elective procedures. Additionally, we invested in point-of-care antigen tests for the office, and we regularly test all our patient-facing staff.

We had corralled enough personal protective equipment to keep our office infusion services operating with our nurses and patients feeling safe. The preparation allowed us to resume in-person visits almost immediately after the Department of Public Health allowed us to reopen.

Once we reopened, we concentrated on in-office visits for patients who were under 65 and at lower risk for COVID-19, while focusing our telemedicine efforts on patients who were older and at higher risk. We’re now back to seeing all patients who want to have in-office visits and are actually above par for our visits. The number of procedures we have performed in the last 3 months is similar to the 3 months before the pandemic.

During the pandemic, Massachusetts had the best conversion to telehealth in the nation, and it worked well for patients and providers. The key was to use several telehealth apps, as using only one may not work for everyone. Having several options made it likely that we would be able to do complete visits and connect with patients. When we needed to, we switched to telephone visits.

All the physicians and staff in our practice are telemedicine enthusiasts, and it will remain a significant part of our practices as long as Medicare, the state health plans, and commercial payers remain supportive.
 

Planning for a surge in screenings

There may be a surge in screenings once more people are vaccinated and comfortable getting back into the office, and we’re planning for this as well. We’ve recruited new physicians and have expanded our available hours for procedures at our ambulatory surgery centers (ASCs). Surprisingly, we have found that there is a lot of interest from physicians for weekend shifts at the ASC, and we now have a physician waiting list for Saturday procedure time.

With the new lower age for recommended screening, there will be a lag with primary care physicians referring their younger patients. This may provide some time to prepare for an increase in screenings resulting from this new policy.

Another strategy that has worked well for us is to train and develop our advanced practitioners into nonphysician experts in GI and liver disease. Greater Boston Gastroenterology has used this strategy since its founding, and we think our most experienced nurse practitioners could rival any office-based gastroenterologist in their acumen and capabilities.

Over the last 3 years we have transitioned our nonphysician practitioners into the inpatient setting. As a result, consults are completed earlier in the day, and we are better able to help coordinate inpatient procedure scheduling, discharge planning, and outpatient follow-up.

The time we spend on training is worth it. It improves customer service, allows us to book appointments with shorter notice, and overall has a positive effect on our bottom line. Utilizing our advanced providers in this capacity will help us manage any volume increases we see in the near future. In addition, most patients in our community are used to seeing advanced providers in their physician’s office, so the acceptance among our patients is high.
 

Being flexible and favoring strategic planning

Overall, I think the greatest thing we learned during the pandemic is that we need to be flexible. It was a helpful reminder that, in medicine, things are constantly changing. I remember when passing the GI boards seemed like my final step, but everyone comes to realize it is just the first step in the journey.

As an early-career physician, you should remember the hard work that helped you get to medical school, land a good residency, stand out to get a fellowship, and master your specialty. Harness that personal drive and energy and keep moving forward. Remember that your first job is unlikely to be your last. Try not to see your choices as either/or – either academic or private practice, hospital-employed or self-employed. The boundaries are blurring. We have long careers and face myriad opportunities for professional advancement.

Be patient. Some goals take time to achieve. At each stage be prepared to work hard, use your time wisely, and try not to lose sight of maximizing your professional happiness.
 

Dr. Dickstein is a practicing gastroenterologist at Greater Boston Gastroenterology in Framingham, Mass., and serves on the executive committee of the Digestive Health Physicians Association. He has no conflicts to declare.

How did your career pathway lead you to working at a health tech startup?

I’ve always had an interest in technology – in fact, it was part of the reason I chose gastroenterology. When I finished GI fellowship, I decided to stay in academics because of an opportunity to lead clinical innovation efforts at my institution’s patient safety institute. This role provided protected time to foster external and internal partnerships around technology. It also gave me an opportunity to pursue clinical research and administrative experiences. While I enjoyed all three paths, it became clear that health technology was my passion. While the opportunity to join a startup was largely serendipitous – I met the founder of the company after presenting at a digital medicine conference – it also happened as a result of the steps outlined in a subsequent question. Not long after learning about the company, I made the transition to part-time faculty/clinical status and full-time chief medical officer (CMO).

What do you do as CMO?

There is no one answer to this question. It will depend on a number of variables, especially the type of business (for example, diagnostic, drug, digital, direct care management, and so on), stage of company (for example, concept, seed, series A/B/C, public), and the existing background of company founders (for example, technical, clinical, operations, and so on). Generally speaking, the earlier the stage of the company, the more hats you’ll wear (though this also means more risk; more on that later). An early-stage company was appealing to me because it gave me an opportunity to apply many of the same critical-thinking and problem-solving skills in clinical medicine to a host of other challenges. For example, as a practicing gastroenterologist, I know the pain points in the delivery of GI care and the challenges that my patients encounter. I then ask how can I develop our technology and product platform to address these issues. Also understanding how value and quality are measured in GI practice makes it easier to convey the effect of the solutions that are built and prioritize their development. In my current role I contribute to the following areas:

• Clinical strategy and vision. This means understanding the clinical need the company is trying to address at a fundamental level and designing how the technology or solution can address that need in a meaningful way. This includes working directly with technology and product teams to create a roadmap for how the technology/solution will continue to drive impact.
• Clinical care leadership. If the company employs or works with health professionals in any capacity, this usually involves developing clinical protocols and providing clinical direction. 
• Clinical outcomes. This means being responsible for understanding and/or developing the metrics that will be used to demonstrate impact of the technology/solution. This includes designing clinical studies and being responsible for their execution.
• Stakeholder engagement. This means interfacing internally with nearly every aspect of the company and interacting externally with customers (usually medical peers and executives), investors, other companies, and key opinion leaders in the field.
• Regulatory. For companies pursuing Food and Drug Administration clearance or approval for their product, this entails developing a strategy and executing it.
• Research & development. This involves creating and executing a roadmap for integrating new technologies/ideas that generally complement the initial problem you are trying to solve.  

What do you enjoy most about working at a startup?

The variety of experience, the flexibility, the fast pace, the ability to work creatively, and the potential to make a large-scale impact are all aspects of the job that I enjoy. The ability to continue clinical practice is important to me and is a major plus. 
 

What do you find most challenging about working at a startup?

One of the biggest differences between a startup and a traditional clinical role is the degree of uncertainty that permeates the entire experience. It took some time for me to adjust to the relative volatility/risk associated with this type of work. Unlike an academic, administrative, or private practice job, things can change very quickly (as in a 24-hour period or less!). This can encompass a number of changes, such as funding, leadership, strategic direction, business model, and staffing, to name a few. What I’ve learned is that this doesn’t always mean changing for the worse, but it does mean things changing near constantly. Being mentally prepared to adapt quickly and frequently to big changes is part of the experience. 
 

What are the ways that GIs can get involved in startups?

Gastroenterologists have more opportunities than most physicians due to the diversity of conditions we treat and the large corresponding number of unmet needs we encounter. There is also the inherent innovation potential associated with new applications in endoscopy, diagnostics, and drug therapies. As a result, there are a number of ways to get involved:

• This often takes the form of “spinning out” research from an academic institution but can also be done successfully from private practice, particularly in the context of new devices/services. Another related option is to license your technology to a company, which offloads the operational aspects of running a business.
• Provide consulting/advisory support. Many early-stage companies cannot afford to hire a full-time physician, but they are open to consulting arrangements (and of course volunteer work). Don’t hesitate to directly contact companies that are interesting to you. These opportunities are possible even while in clinical training.
• Work part time or full time. The majority of startups are supportive of physicians continuing to practice clinically. This makes engaging in a part-time position financially feasible for both parties. Given the relatively high remuneration for gastroenterologists working clinically, a full-time position at a startup may require a financial tradeoff (that is, lower short-term salary for a potential larger long-term gain – note the emphasis on “potential”).  
• Invest in early-stage companies. Physicians can become angel investors for early-stage companies. Given the relatively time-intensive process of finding new opportunities and conducting due diligence, this often takes the form of pooling funds into angel networks that can distribute the execution of investments more efficiently. 

How would a fellow or early-career GI who is interested in startups pursue this career pathway?

The first step I recommend is self-reflection – what about the startup experience is interesting to you? Not all aspects appeal to everyone, and not all options provide the same opportunities. Spending time deciding which specific aspects of the startup experience appeal to you will make it easier to find the right opportunity. A concurrent step is to build expertise. This can take many forms, including traditional basic science or clinical research, but also includes implementation, evaluation/analysis, design, education, regulation, policy, and so on. The next step is to proactively meet people who are doing what you are interested in doing. Reach out to mentors, alumni, faculty, and friends. Conferences and social media are also great places to network. Other potential paths can include developing expertise in an allied functional area that can be later leveraged into a startup role (for example, experience at pharma, payer, regulatory, and so on). Many of these organizations have programs specifically geared toward physicians making a transition. In addition, another potential option is to seek additional education through an MBA where internships, recruitment programs, and robust alumni networks can be helpful in finding placement.

What if I want to learn more about the health technology startup experience?

The AGA Center for GI Innovation and Technology (CGIT) has a number of programs throughout the year, including the annual Tech Summit where you can learn about new companies, ideas, and technologies from like-minded individuals. I also invite you to reach out to me directly via Twitter, LinkedIn, or email with specific questions. As gastroenterologists, we are fortunate to work in a field full of innovation and new ideas. As a result, there are many meaningful career paths available to those interested in gastroenterology and technology. Whether providing direct clinical care with the latest endoscopic techniques or developing the next digital therapy, the opportunities for gastroenterologists will only continue to grow.

Dr. Mathews is chief medical officer at Vivante Health and assistant professor of medicine at Johns Hopkins Medicine in Baltimore. He is an officer at Vivante Health with stock options, but he reports having nothing else to disclose.

How did your career pathway lead you to working at a health tech startup?

I’ve always had an interest in technology – in fact, it was part of the reason I chose gastroenterology. When I finished GI fellowship, I decided to stay in academics because of an opportunity to lead clinical innovation efforts at my institution’s patient safety institute. This role provided protected time to foster external and internal partnerships around technology. It also gave me an opportunity to pursue clinical research and administrative experiences. While I enjoyed all three paths, it became clear that health technology was my passion. While the opportunity to join a startup was largely serendipitous – I met the founder of the company after presenting at a digital medicine conference – it also happened as a result of the steps outlined in a subsequent question. Not long after learning about the company, I made the transition to part-time faculty/clinical status and full-time chief medical officer (CMO).

What do you do as CMO?

There is no one answer to this question. It will depend on a number of variables, especially the type of business (for example, diagnostic, drug, digital, direct care management, and so on), stage of company (for example, concept, seed, series A/B/C, public), and the existing background of company founders (for example, technical, clinical, operations, and so on). Generally speaking, the earlier the stage of the company, the more hats you’ll wear (though this also means more risk; more on that later). An early-stage company was appealing to me because it gave me an opportunity to apply many of the same critical-thinking and problem-solving skills in clinical medicine to a host of other challenges. For example, as a practicing gastroenterologist, I know the pain points in the delivery of GI care and the challenges that my patients encounter. I then ask how can I develop our technology and product platform to address these issues. Also understanding how value and quality are measured in GI practice makes it easier to convey the effect of the solutions that are built and prioritize their development. In my current role I contribute to the following areas:

• Clinical strategy and vision. This means understanding the clinical need the company is trying to address at a fundamental level and designing how the technology or solution can address that need in a meaningful way. This includes working directly with technology and product teams to create a roadmap for how the technology/solution will continue to drive impact.
• Clinical care leadership. If the company employs or works with health professionals in any capacity, this usually involves developing clinical protocols and providing clinical direction. 
• Clinical outcomes. This means being responsible for understanding and/or developing the metrics that will be used to demonstrate impact of the technology/solution. This includes designing clinical studies and being responsible for their execution.
• Stakeholder engagement. This means interfacing internally with nearly every aspect of the company and interacting externally with customers (usually medical peers and executives), investors, other companies, and key opinion leaders in the field.
• Regulatory. For companies pursuing Food and Drug Administration clearance or approval for their product, this entails developing a strategy and executing it.
• Research & development. This involves creating and executing a roadmap for integrating new technologies/ideas that generally complement the initial problem you are trying to solve.  

What do you enjoy most about working at a startup?

The variety of experience, the flexibility, the fast pace, the ability to work creatively, and the potential to make a large-scale impact are all aspects of the job that I enjoy. The ability to continue clinical practice is important to me and is a major plus. 
 

What do you find most challenging about working at a startup?

One of the biggest differences between a startup and a traditional clinical role is the degree of uncertainty that permeates the entire experience. It took some time for me to adjust to the relative volatility/risk associated with this type of work. Unlike an academic, administrative, or private practice job, things can change very quickly (as in a 24-hour period or less!). This can encompass a number of changes, such as funding, leadership, strategic direction, business model, and staffing, to name a few. What I’ve learned is that this doesn’t always mean changing for the worse, but it does mean things changing near constantly. Being mentally prepared to adapt quickly and frequently to big changes is part of the experience. 
 

What are the ways that GIs can get involved in startups?

Gastroenterologists have more opportunities than most physicians due to the diversity of conditions we treat and the large corresponding number of unmet needs we encounter. There is also the inherent innovation potential associated with new applications in endoscopy, diagnostics, and drug therapies. As a result, there are a number of ways to get involved:

• This often takes the form of “spinning out” research from an academic institution but can also be done successfully from private practice, particularly in the context of new devices/services. Another related option is to license your technology to a company, which offloads the operational aspects of running a business.
• Provide consulting/advisory support. Many early-stage companies cannot afford to hire a full-time physician, but they are open to consulting arrangements (and of course volunteer work). Don’t hesitate to directly contact companies that are interesting to you. These opportunities are possible even while in clinical training.
• Work part time or full time. The majority of startups are supportive of physicians continuing to practice clinically. This makes engaging in a part-time position financially feasible for both parties. Given the relatively high remuneration for gastroenterologists working clinically, a full-time position at a startup may require a financial tradeoff (that is, lower short-term salary for a potential larger long-term gain – note the emphasis on “potential”).  
• Invest in early-stage companies. Physicians can become angel investors for early-stage companies. Given the relatively time-intensive process of finding new opportunities and conducting due diligence, this often takes the form of pooling funds into angel networks that can distribute the execution of investments more efficiently. 

How would a fellow or early-career GI who is interested in startups pursue this career pathway?

The first step I recommend is self-reflection – what about the startup experience is interesting to you? Not all aspects appeal to everyone, and not all options provide the same opportunities. Spending time deciding which specific aspects of the startup experience appeal to you will make it easier to find the right opportunity. A concurrent step is to build expertise. This can take many forms, including traditional basic science or clinical research, but also includes implementation, evaluation/analysis, design, education, regulation, policy, and so on. The next step is to proactively meet people who are doing what you are interested in doing. Reach out to mentors, alumni, faculty, and friends. Conferences and social media are also great places to network. Other potential paths can include developing expertise in an allied functional area that can be later leveraged into a startup role (for example, experience at pharma, payer, regulatory, and so on). Many of these organizations have programs specifically geared toward physicians making a transition. In addition, another potential option is to seek additional education through an MBA where internships, recruitment programs, and robust alumni networks can be helpful in finding placement.

What if I want to learn more about the health technology startup experience?

The AGA Center for GI Innovation and Technology (CGIT) has a number of programs throughout the year, including the annual Tech Summit where you can learn about new companies, ideas, and technologies from like-minded individuals. I also invite you to reach out to me directly via Twitter, LinkedIn, or email with specific questions. As gastroenterologists, we are fortunate to work in a field full of innovation and new ideas. As a result, there are many meaningful career paths available to those interested in gastroenterology and technology. Whether providing direct clinical care with the latest endoscopic techniques or developing the next digital therapy, the opportunities for gastroenterologists will only continue to grow.

Dr. Mathews is chief medical officer at Vivante Health and assistant professor of medicine at Johns Hopkins Medicine in Baltimore. He is an officer at Vivante Health with stock options, but he reports having nothing else to disclose.

How did your career pathway lead you to working at a health tech startup?

I’ve always had an interest in technology – in fact, it was part of the reason I chose gastroenterology. When I finished GI fellowship, I decided to stay in academics because of an opportunity to lead clinical innovation efforts at my institution’s patient safety institute. This role provided protected time to foster external and internal partnerships around technology. It also gave me an opportunity to pursue clinical research and administrative experiences. While I enjoyed all three paths, it became clear that health technology was my passion. While the opportunity to join a startup was largely serendipitous – I met the founder of the company after presenting at a digital medicine conference – it also happened as a result of the steps outlined in a subsequent question. Not long after learning about the company, I made the transition to part-time faculty/clinical status and full-time chief medical officer (CMO).

What do you do as CMO?

There is no one answer to this question. It will depend on a number of variables, especially the type of business (for example, diagnostic, drug, digital, direct care management, and so on), stage of company (for example, concept, seed, series A/B/C, public), and the existing background of company founders (for example, technical, clinical, operations, and so on). Generally speaking, the earlier the stage of the company, the more hats you’ll wear (though this also means more risk; more on that later). An early-stage company was appealing to me because it gave me an opportunity to apply many of the same critical-thinking and problem-solving skills in clinical medicine to a host of other challenges. For example, as a practicing gastroenterologist, I know the pain points in the delivery of GI care and the challenges that my patients encounter. I then ask how can I develop our technology and product platform to address these issues. Also understanding how value and quality are measured in GI practice makes it easier to convey the effect of the solutions that are built and prioritize their development. In my current role I contribute to the following areas:

• Clinical strategy and vision. This means understanding the clinical need the company is trying to address at a fundamental level and designing how the technology or solution can address that need in a meaningful way. This includes working directly with technology and product teams to create a roadmap for how the technology/solution will continue to drive impact.
• Clinical care leadership. If the company employs or works with health professionals in any capacity, this usually involves developing clinical protocols and providing clinical direction. 
• Clinical outcomes. This means being responsible for understanding and/or developing the metrics that will be used to demonstrate impact of the technology/solution. This includes designing clinical studies and being responsible for their execution.
• Stakeholder engagement. This means interfacing internally with nearly every aspect of the company and interacting externally with customers (usually medical peers and executives), investors, other companies, and key opinion leaders in the field.
• Regulatory. For companies pursuing Food and Drug Administration clearance or approval for their product, this entails developing a strategy and executing it.
• Research & development. This involves creating and executing a roadmap for integrating new technologies/ideas that generally complement the initial problem you are trying to solve.  

What do you enjoy most about working at a startup?

The variety of experience, the flexibility, the fast pace, the ability to work creatively, and the potential to make a large-scale impact are all aspects of the job that I enjoy. The ability to continue clinical practice is important to me and is a major plus. 
 

What do you find most challenging about working at a startup?

One of the biggest differences between a startup and a traditional clinical role is the degree of uncertainty that permeates the entire experience. It took some time for me to adjust to the relative volatility/risk associated with this type of work. Unlike an academic, administrative, or private practice job, things can change very quickly (as in a 24-hour period or less!). This can encompass a number of changes, such as funding, leadership, strategic direction, business model, and staffing, to name a few. What I’ve learned is that this doesn’t always mean changing for the worse, but it does mean things changing near constantly. Being mentally prepared to adapt quickly and frequently to big changes is part of the experience. 
 

What are the ways that GIs can get involved in startups?

Gastroenterologists have more opportunities than most physicians due to the diversity of conditions we treat and the large corresponding number of unmet needs we encounter. There is also the inherent innovation potential associated with new applications in endoscopy, diagnostics, and drug therapies. As a result, there are a number of ways to get involved:

• This often takes the form of “spinning out” research from an academic institution but can also be done successfully from private practice, particularly in the context of new devices/services. Another related option is to license your technology to a company, which offloads the operational aspects of running a business.
• Provide consulting/advisory support. Many early-stage companies cannot afford to hire a full-time physician, but they are open to consulting arrangements (and of course volunteer work). Don’t hesitate to directly contact companies that are interesting to you. These opportunities are possible even while in clinical training.
• Work part time or full time. The majority of startups are supportive of physicians continuing to practice clinically. This makes engaging in a part-time position financially feasible for both parties. Given the relatively high remuneration for gastroenterologists working clinically, a full-time position at a startup may require a financial tradeoff (that is, lower short-term salary for a potential larger long-term gain – note the emphasis on “potential”).  
• Invest in early-stage companies. Physicians can become angel investors for early-stage companies. Given the relatively time-intensive process of finding new opportunities and conducting due diligence, this often takes the form of pooling funds into angel networks that can distribute the execution of investments more efficiently. 

How would a fellow or early-career GI who is interested in startups pursue this career pathway?

The first step I recommend is self-reflection – what about the startup experience is interesting to you? Not all aspects appeal to everyone, and not all options provide the same opportunities. Spending time deciding which specific aspects of the startup experience appeal to you will make it easier to find the right opportunity. A concurrent step is to build expertise. This can take many forms, including traditional basic science or clinical research, but also includes implementation, evaluation/analysis, design, education, regulation, policy, and so on. The next step is to proactively meet people who are doing what you are interested in doing. Reach out to mentors, alumni, faculty, and friends. Conferences and social media are also great places to network. Other potential paths can include developing expertise in an allied functional area that can be later leveraged into a startup role (for example, experience at pharma, payer, regulatory, and so on). Many of these organizations have programs specifically geared toward physicians making a transition. In addition, another potential option is to seek additional education through an MBA where internships, recruitment programs, and robust alumni networks can be helpful in finding placement.

What if I want to learn more about the health technology startup experience?

The AGA Center for GI Innovation and Technology (CGIT) has a number of programs throughout the year, including the annual Tech Summit where you can learn about new companies, ideas, and technologies from like-minded individuals. I also invite you to reach out to me directly via Twitter, LinkedIn, or email with specific questions. As gastroenterologists, we are fortunate to work in a field full of innovation and new ideas. As a result, there are many meaningful career paths available to those interested in gastroenterology and technology. Whether providing direct clinical care with the latest endoscopic techniques or developing the next digital therapy, the opportunities for gastroenterologists will only continue to grow.

Dr. Mathews is chief medical officer at Vivante Health and assistant professor of medicine at Johns Hopkins Medicine in Baltimore. He is an officer at Vivante Health with stock options, but he reports having nothing else to disclose.

In the acute care setting, providers of care for inflammatory bowel disease (IBD) patients are often faced with the dilemma of providing effective abdominal pain management in a population that has worse outcomes with both opioid and NSAID therapy. There is increased mortality associated with opioid use and risk of disease relapse with NSAID use in IBD patients.^1,2 Due to this, patients often feel that their pain is inadequately addressed.^3,4 There are multiple sources of abdominal pain in IBD, and understanding the mechanisms and presentations can help identify effective treatments. We will review pharmacologic and supportive therapies to optimize pain management in IBD.

Common pain presentations in IBD

Visceral pain is a dull, poorly localized, cramping pain from intestinal distension. It is associated with inflammation, dysmotility, obstruction, and visceral hypersensitivity. Somatic and parietal pain is sharp, intense, and often localizable. Somatic pain originates from surrounding skin or muscles, and parietal pain arises from irritation of the peritoneum.⁵ We will review two common pain presentations in IBD.

Case 1: Mr. A is a 32-year-old male with stricturing small bowel Crohn’s disease s/p small bowel resection, who presents to the ED with 3 days of abdominal pain, nausea, and vomiting. C-reactive protein is elevated to 6.8 mg/dL (normal 0.0 – 0.6 mg/dL), and CT is consistent with active small bowel inflammation, intraabdominal abscess at the anastomosis, and associated partial small bowel obstruction. He describes a sharp, intense abdominal pain with cramping. His exam is significant for diffuse abdominal tenderness and distension.

Case 2: Ms. B is a 28-year-old female with ulcerative colitis on mesalamine monotherapy who presents to the hospital for rectal bleeding and cramping abdominal pain. After 3 days of IV steroids her rectal bleeding has resolved, and CRP has normalized. However, she continues to have dull, cramping abdominal pain. Ibuprofen has improved this pain in the past.

Mr. A is having somatic pain from inflammation, abscess, and partial bowel obstruction. He also has visceral pain from luminal distension proximal to the obstruction. Ms. B is having visceral pain despite resolution of inflammation, which may be from postinflammatory visceral hypersensitivity.
 

Etiologies of pain

It’s best to group pain etiologies into inflammatory and noninflammatory causes. Inflammatory pain can be secondary to infection, such as abscess or enteric infection, active bowel inflammation, or disease complications (that is, enteric fistula). It is important to recognize that patients with active inflammation may also have noninflammatory pain. These include small bowel obstruction, strictures, adhesions, narcotic bowel syndrome, bacterial overgrowth, and visceral hypersensitivity. See figure 1.

Courtesy Dr. Mehwish Ahmed and Dr. Jami Kinnucan

The brain-gut connection matters

Abdominal pain in IBD patients starts from painful stimuli in the gut. In addition to direct pain pathways, multiple areas of the brain modulate perception of pain.⁶ Patients with psychiatric comorbidities have increased perception of abdominal pain.⁷ In fact, high perceived stress is associated with disease relapse.⁸ Treatment of psychiatric disorders improves these symptoms with lasting effects.⁹ Addressing psychological and psychosocial needs is essential to successful pain management with long-term effect on quality of life and pain perception in IBD patients.
 

What are my options?

When IBD patients present with acute abdominal pain, it is important to directly address their pain as one of your primary concerns and provide them with a management plan. While this seems obvious, it is not routinely done.3-4

Next, it is important to identify the cause, whether it be infection, obstruction, active inflammation, or functional abdominal pain. In the case of active disease, in addition to steroids and optimization of IBD therapies, acetaminophen and antispasmodics can be used for initial pain management. Supportive therapies include sleep hygiene, physical activity, and psychotherapy. If initial treatments are unsuccessful in the acute setting, and presentation is consistent with somatic pain, it may be necessary to escalate to tramadol, opioid, or NSAID therapy. For visceral pain, a neuromodulator, such as a tricyclic antidepressant or gabapentin, may have greater effect. Bupropion, SNRIs, and SSRIs are options; however, they may not be effective in the acute setting. More recent focus in the IBD community has questioned the role of cannabinoids on pain in IBD patients. Cannabis has been shown in a few small studies to provide pain relief in IBD patients with active inflammation.^10-11 In patients with mechanical causes for pain, management of obstruction is an important part of the treatment plan.
 

Let’s talk about opioids in IBD patients

Chronic narcotic use in IBD is associated with worse outcomes. So when is it okay to use opioid therapies in IBD patients? Postoperative patients, patients with severe perianal disease, or those who fail alternative pain management strategies may require opioid medications. The association with mortality and opioids in IBD is with patients who require moderate to heavy use, which is defined as being prescribed opioids more than once a year. Opioid use in IBD patients is also associated with increased risk of readmissions and poor surgical outcomes.^12-13 Tramadol does not have increased mortality risk.¹ If selecting opioid therapy in managing pain in IBD, it is important to define the course of therapy, with a clear goal of discontinuation after the acute episode. Opioids should be used in tandem with alternative strategies. Patients should be counseled on the synergistic effect of acetaminophen with opioids, which may allow lower effective doses of opioids.

What about NSAID use in IBD patients?

NSAIDs have negative effects in the gastrointestinal tract due to inhibition of protective prostaglandins. They also alter the gut microbiome, although clinical implications of this are unknown.¹⁴ A small study showed that IBD patients who used NSAIDs had increased risk of disease relapse.² Symptoms of relapse would present within 2-9 days of exposure; however, most had resolution of symptoms within 2-11 days of discontinuation.² Follow-up studies have not reliably found that NSAIDs are associated with disease relapse.⁸ and thus NSAIDs may be used sparingly if needed in the acute setting.

Case Review: How do we approach Mr. A and Ms. B?

Mr. A presented with a partial small bowel obstruction and abscess. His pain presentation was consistent with both visceral and somatic pain etiologies. In addition to treating active inflammation and infection, bowel rest, acetaminophen, and antispasmodics can be initiated for pain control. Concomitantly, gabapentin, TCA, or SNRI can be initiated for neurobiological pain but may have limited benefit in the acute hospitalized setting. Social work may identify needs that affect pain perception and assist in addressing those needs. If abdominal pain persists, tramadol or hydrocodone-acetaminophen can be considered.

Ms. B presented with disease relapse, but despite improving inflammatory markers she had continued cramping abdominal pain, which can be consistent with visceral hypersensitivity. Antispasmodic and neuromodulating agents, such as a TCA, could be effective. We can recommend discontinuation of chronic ibuprofen due to risk of intestinal inflammation. Patients may inquire about adjuvant cannabis in pain management. While cannabis can be considered, further research is needed to recommend its regular use.
 

Conclusion

Acute abdominal pain management in IBD can be challenging for providers when typical options are limited in this population. Addressing inflammatory, mechanical, neurobiological, and psychological influences is vital to appropriately address pain. Having a structured plan for pain management in IBD can improve outcomes by decreasing recurrent hospitalizations and use of opioids.¹⁵ Figure 2 presents an overview.

Courtesy Dr. Mehwish Ahmed and Dr. Jami Kinnucan

Dr. Ahmed is a second-year internal medicine resident at the University of Michigan, Ann Arbor. Dr. Kinnucan is with the department of internal medicine and the division of gastroenterology and hepatology and is an assistant professor of medicine in the division of gastroenterology, both at the University of Michigan. They have no conflicts of interest.

References

1. Burr NE et al. Clin Gastroenterol Hepatol. 2018 Apr;16(4):534-41.e6.

2. Takeuchi K et al. Clin Gastroenterol Hepatol. 2006 Feb;4(2):196-202.

3. Bernhofer EI et al. Gastroenterol Nurs. 2017 May/Jun;40(3):200-7.

4. Zeitz J et al. PLoS One. 2016 Jun 22;11(6):e0156666.

5. Srinath A et al. Inflamm Bowel Dis. 2014 Dec;20(12):2433-49.

6. Docherty MJ et al. Gastroenterol Hepatol (N Y). 2011 Sep;7(9):592-601.

7. Elsenbruch S et al. Gut. 2010 Apr;59(4):489-95.

8. Bernstein CN et al. Am J Gastroenterol. 2010 Sep;105(9):1994-2002.

9. Palsson OS and Whitehead WE. Clin Gastroenterol Hepatol. 2013 Mar;11(3):208-16; quiz e22-3.

10. Swaminath A et al. Inflamm Bowel Dis. 2019 Mar; 25(3):427-35.

11. Naftali T et al. Clin Gastroenterol Hepatol. 2013 Oct;11(10):1276-80.e1.

12. Sultan K and Swaminath A. J Crohns Colitis. 2020 Sep 16;14(9):1188-89.

13. Hirsch A et al. J Gastrointest Surg. 2015 Oct;19(10):1852-61.

14. Rogers MAM and Aronoff DM. Clin Microbiol Infect. 2016;22(2):178.e1-178.e9.

15. Kaimakliotis P et al. Int J Colorectal Dis. 2021 Jun;36(6):1193-200.
 

In the acute care setting, providers of care for inflammatory bowel disease (IBD) patients are often faced with the dilemma of providing effective abdominal pain management in a population that has worse outcomes with both opioid and NSAID therapy. There is increased mortality associated with opioid use and risk of disease relapse with NSAID use in IBD patients.^1,2 Due to this, patients often feel that their pain is inadequately addressed.^3,4 There are multiple sources of abdominal pain in IBD, and understanding the mechanisms and presentations can help identify effective treatments. We will review pharmacologic and supportive therapies to optimize pain management in IBD.

Common pain presentations in IBD

Visceral pain is a dull, poorly localized, cramping pain from intestinal distension. It is associated with inflammation, dysmotility, obstruction, and visceral hypersensitivity. Somatic and parietal pain is sharp, intense, and often localizable. Somatic pain originates from surrounding skin or muscles, and parietal pain arises from irritation of the peritoneum.⁵ We will review two common pain presentations in IBD.

Case 1: Mr. A is a 32-year-old male with stricturing small bowel Crohn’s disease s/p small bowel resection, who presents to the ED with 3 days of abdominal pain, nausea, and vomiting. C-reactive protein is elevated to 6.8 mg/dL (normal 0.0 – 0.6 mg/dL), and CT is consistent with active small bowel inflammation, intraabdominal abscess at the anastomosis, and associated partial small bowel obstruction. He describes a sharp, intense abdominal pain with cramping. His exam is significant for diffuse abdominal tenderness and distension.

Case 2: Ms. B is a 28-year-old female with ulcerative colitis on mesalamine monotherapy who presents to the hospital for rectal bleeding and cramping abdominal pain. After 3 days of IV steroids her rectal bleeding has resolved, and CRP has normalized. However, she continues to have dull, cramping abdominal pain. Ibuprofen has improved this pain in the past.

Mr. A is having somatic pain from inflammation, abscess, and partial bowel obstruction. He also has visceral pain from luminal distension proximal to the obstruction. Ms. B is having visceral pain despite resolution of inflammation, which may be from postinflammatory visceral hypersensitivity.
 

Etiologies of pain

It’s best to group pain etiologies into inflammatory and noninflammatory causes. Inflammatory pain can be secondary to infection, such as abscess or enteric infection, active bowel inflammation, or disease complications (that is, enteric fistula). It is important to recognize that patients with active inflammation may also have noninflammatory pain. These include small bowel obstruction, strictures, adhesions, narcotic bowel syndrome, bacterial overgrowth, and visceral hypersensitivity. See figure 1.

Courtesy Dr. Mehwish Ahmed and Dr. Jami Kinnucan

The brain-gut connection matters

Abdominal pain in IBD patients starts from painful stimuli in the gut. In addition to direct pain pathways, multiple areas of the brain modulate perception of pain.⁶ Patients with psychiatric comorbidities have increased perception of abdominal pain.⁷ In fact, high perceived stress is associated with disease relapse.⁸ Treatment of psychiatric disorders improves these symptoms with lasting effects.⁹ Addressing psychological and psychosocial needs is essential to successful pain management with long-term effect on quality of life and pain perception in IBD patients.
 

What are my options?

When IBD patients present with acute abdominal pain, it is important to directly address their pain as one of your primary concerns and provide them with a management plan. While this seems obvious, it is not routinely done.3-4

Next, it is important to identify the cause, whether it be infection, obstruction, active inflammation, or functional abdominal pain. In the case of active disease, in addition to steroids and optimization of IBD therapies, acetaminophen and antispasmodics can be used for initial pain management. Supportive therapies include sleep hygiene, physical activity, and psychotherapy. If initial treatments are unsuccessful in the acute setting, and presentation is consistent with somatic pain, it may be necessary to escalate to tramadol, opioid, or NSAID therapy. For visceral pain, a neuromodulator, such as a tricyclic antidepressant or gabapentin, may have greater effect. Bupropion, SNRIs, and SSRIs are options; however, they may not be effective in the acute setting. More recent focus in the IBD community has questioned the role of cannabinoids on pain in IBD patients. Cannabis has been shown in a few small studies to provide pain relief in IBD patients with active inflammation.^10-11 In patients with mechanical causes for pain, management of obstruction is an important part of the treatment plan.
 

Let’s talk about opioids in IBD patients

Chronic narcotic use in IBD is associated with worse outcomes. So when is it okay to use opioid therapies in IBD patients? Postoperative patients, patients with severe perianal disease, or those who fail alternative pain management strategies may require opioid medications. The association with mortality and opioids in IBD is with patients who require moderate to heavy use, which is defined as being prescribed opioids more than once a year. Opioid use in IBD patients is also associated with increased risk of readmissions and poor surgical outcomes.^12-13 Tramadol does not have increased mortality risk.¹ If selecting opioid therapy in managing pain in IBD, it is important to define the course of therapy, with a clear goal of discontinuation after the acute episode. Opioids should be used in tandem with alternative strategies. Patients should be counseled on the synergistic effect of acetaminophen with opioids, which may allow lower effective doses of opioids.

What about NSAID use in IBD patients?

NSAIDs have negative effects in the gastrointestinal tract due to inhibition of protective prostaglandins. They also alter the gut microbiome, although clinical implications of this are unknown.¹⁴ A small study showed that IBD patients who used NSAIDs had increased risk of disease relapse.² Symptoms of relapse would present within 2-9 days of exposure; however, most had resolution of symptoms within 2-11 days of discontinuation.² Follow-up studies have not reliably found that NSAIDs are associated with disease relapse.⁸ and thus NSAIDs may be used sparingly if needed in the acute setting.

Case Review: How do we approach Mr. A and Ms. B?

Mr. A presented with a partial small bowel obstruction and abscess. His pain presentation was consistent with both visceral and somatic pain etiologies. In addition to treating active inflammation and infection, bowel rest, acetaminophen, and antispasmodics can be initiated for pain control. Concomitantly, gabapentin, TCA, or SNRI can be initiated for neurobiological pain but may have limited benefit in the acute hospitalized setting. Social work may identify needs that affect pain perception and assist in addressing those needs. If abdominal pain persists, tramadol or hydrocodone-acetaminophen can be considered.

Ms. B presented with disease relapse, but despite improving inflammatory markers she had continued cramping abdominal pain, which can be consistent with visceral hypersensitivity. Antispasmodic and neuromodulating agents, such as a TCA, could be effective. We can recommend discontinuation of chronic ibuprofen due to risk of intestinal inflammation. Patients may inquire about adjuvant cannabis in pain management. While cannabis can be considered, further research is needed to recommend its regular use.
 

Conclusion

Acute abdominal pain management in IBD can be challenging for providers when typical options are limited in this population. Addressing inflammatory, mechanical, neurobiological, and psychological influences is vital to appropriately address pain. Having a structured plan for pain management in IBD can improve outcomes by decreasing recurrent hospitalizations and use of opioids.¹⁵ Figure 2 presents an overview.

Courtesy Dr. Mehwish Ahmed and Dr. Jami Kinnucan

Dr. Ahmed is a second-year internal medicine resident at the University of Michigan, Ann Arbor. Dr. Kinnucan is with the department of internal medicine and the division of gastroenterology and hepatology and is an assistant professor of medicine in the division of gastroenterology, both at the University of Michigan. They have no conflicts of interest.

References

1. Burr NE et al. Clin Gastroenterol Hepatol. 2018 Apr;16(4):534-41.e6.

2. Takeuchi K et al. Clin Gastroenterol Hepatol. 2006 Feb;4(2):196-202.

3. Bernhofer EI et al. Gastroenterol Nurs. 2017 May/Jun;40(3):200-7.

4. Zeitz J et al. PLoS One. 2016 Jun 22;11(6):e0156666.

5. Srinath A et al. Inflamm Bowel Dis. 2014 Dec;20(12):2433-49.

6. Docherty MJ et al. Gastroenterol Hepatol (N Y). 2011 Sep;7(9):592-601.

7. Elsenbruch S et al. Gut. 2010 Apr;59(4):489-95.

8. Bernstein CN et al. Am J Gastroenterol. 2010 Sep;105(9):1994-2002.

9. Palsson OS and Whitehead WE. Clin Gastroenterol Hepatol. 2013 Mar;11(3):208-16; quiz e22-3.

10. Swaminath A et al. Inflamm Bowel Dis. 2019 Mar; 25(3):427-35.

11. Naftali T et al. Clin Gastroenterol Hepatol. 2013 Oct;11(10):1276-80.e1.

12. Sultan K and Swaminath A. J Crohns Colitis. 2020 Sep 16;14(9):1188-89.

13. Hirsch A et al. J Gastrointest Surg. 2015 Oct;19(10):1852-61.

14. Rogers MAM and Aronoff DM. Clin Microbiol Infect. 2016;22(2):178.e1-178.e9.

15. Kaimakliotis P et al. Int J Colorectal Dis. 2021 Jun;36(6):1193-200.
 

In the acute care setting, providers of care for inflammatory bowel disease (IBD) patients are often faced with the dilemma of providing effective abdominal pain management in a population that has worse outcomes with both opioid and NSAID therapy. There is increased mortality associated with opioid use and risk of disease relapse with NSAID use in IBD patients.^1,2 Due to this, patients often feel that their pain is inadequately addressed.^3,4 There are multiple sources of abdominal pain in IBD, and understanding the mechanisms and presentations can help identify effective treatments. We will review pharmacologic and supportive therapies to optimize pain management in IBD.

Common pain presentations in IBD

Visceral pain is a dull, poorly localized, cramping pain from intestinal distension. It is associated with inflammation, dysmotility, obstruction, and visceral hypersensitivity. Somatic and parietal pain is sharp, intense, and often localizable. Somatic pain originates from surrounding skin or muscles, and parietal pain arises from irritation of the peritoneum.⁵ We will review two common pain presentations in IBD.

Case 1: Mr. A is a 32-year-old male with stricturing small bowel Crohn’s disease s/p small bowel resection, who presents to the ED with 3 days of abdominal pain, nausea, and vomiting. C-reactive protein is elevated to 6.8 mg/dL (normal 0.0 – 0.6 mg/dL), and CT is consistent with active small bowel inflammation, intraabdominal abscess at the anastomosis, and associated partial small bowel obstruction. He describes a sharp, intense abdominal pain with cramping. His exam is significant for diffuse abdominal tenderness and distension.

Case 2: Ms. B is a 28-year-old female with ulcerative colitis on mesalamine monotherapy who presents to the hospital for rectal bleeding and cramping abdominal pain. After 3 days of IV steroids her rectal bleeding has resolved, and CRP has normalized. However, she continues to have dull, cramping abdominal pain. Ibuprofen has improved this pain in the past.

Mr. A is having somatic pain from inflammation, abscess, and partial bowel obstruction. He also has visceral pain from luminal distension proximal to the obstruction. Ms. B is having visceral pain despite resolution of inflammation, which may be from postinflammatory visceral hypersensitivity.
 

Etiologies of pain

It’s best to group pain etiologies into inflammatory and noninflammatory causes. Inflammatory pain can be secondary to infection, such as abscess or enteric infection, active bowel inflammation, or disease complications (that is, enteric fistula). It is important to recognize that patients with active inflammation may also have noninflammatory pain. These include small bowel obstruction, strictures, adhesions, narcotic bowel syndrome, bacterial overgrowth, and visceral hypersensitivity. See figure 1.

Courtesy Dr. Mehwish Ahmed and Dr. Jami Kinnucan

The brain-gut connection matters

Abdominal pain in IBD patients starts from painful stimuli in the gut. In addition to direct pain pathways, multiple areas of the brain modulate perception of pain.⁶ Patients with psychiatric comorbidities have increased perception of abdominal pain.⁷ In fact, high perceived stress is associated with disease relapse.⁸ Treatment of psychiatric disorders improves these symptoms with lasting effects.⁹ Addressing psychological and psychosocial needs is essential to successful pain management with long-term effect on quality of life and pain perception in IBD patients.
 

What are my options?

When IBD patients present with acute abdominal pain, it is important to directly address their pain as one of your primary concerns and provide them with a management plan. While this seems obvious, it is not routinely done.3-4

Next, it is important to identify the cause, whether it be infection, obstruction, active inflammation, or functional abdominal pain. In the case of active disease, in addition to steroids and optimization of IBD therapies, acetaminophen and antispasmodics can be used for initial pain management. Supportive therapies include sleep hygiene, physical activity, and psychotherapy. If initial treatments are unsuccessful in the acute setting, and presentation is consistent with somatic pain, it may be necessary to escalate to tramadol, opioid, or NSAID therapy. For visceral pain, a neuromodulator, such as a tricyclic antidepressant or gabapentin, may have greater effect. Bupropion, SNRIs, and SSRIs are options; however, they may not be effective in the acute setting. More recent focus in the IBD community has questioned the role of cannabinoids on pain in IBD patients. Cannabis has been shown in a few small studies to provide pain relief in IBD patients with active inflammation.^10-11 In patients with mechanical causes for pain, management of obstruction is an important part of the treatment plan.
 

Let’s talk about opioids in IBD patients

Chronic narcotic use in IBD is associated with worse outcomes. So when is it okay to use opioid therapies in IBD patients? Postoperative patients, patients with severe perianal disease, or those who fail alternative pain management strategies may require opioid medications. The association with mortality and opioids in IBD is with patients who require moderate to heavy use, which is defined as being prescribed opioids more than once a year. Opioid use in IBD patients is also associated with increased risk of readmissions and poor surgical outcomes.^12-13 Tramadol does not have increased mortality risk.¹ If selecting opioid therapy in managing pain in IBD, it is important to define the course of therapy, with a clear goal of discontinuation after the acute episode. Opioids should be used in tandem with alternative strategies. Patients should be counseled on the synergistic effect of acetaminophen with opioids, which may allow lower effective doses of opioids.

What about NSAID use in IBD patients?

NSAIDs have negative effects in the gastrointestinal tract due to inhibition of protective prostaglandins. They also alter the gut microbiome, although clinical implications of this are unknown.¹⁴ A small study showed that IBD patients who used NSAIDs had increased risk of disease relapse.² Symptoms of relapse would present within 2-9 days of exposure; however, most had resolution of symptoms within 2-11 days of discontinuation.² Follow-up studies have not reliably found that NSAIDs are associated with disease relapse.⁸ and thus NSAIDs may be used sparingly if needed in the acute setting.

Case Review: How do we approach Mr. A and Ms. B?

Mr. A presented with a partial small bowel obstruction and abscess. His pain presentation was consistent with both visceral and somatic pain etiologies. In addition to treating active inflammation and infection, bowel rest, acetaminophen, and antispasmodics can be initiated for pain control. Concomitantly, gabapentin, TCA, or SNRI can be initiated for neurobiological pain but may have limited benefit in the acute hospitalized setting. Social work may identify needs that affect pain perception and assist in addressing those needs. If abdominal pain persists, tramadol or hydrocodone-acetaminophen can be considered.

Ms. B presented with disease relapse, but despite improving inflammatory markers she had continued cramping abdominal pain, which can be consistent with visceral hypersensitivity. Antispasmodic and neuromodulating agents, such as a TCA, could be effective. We can recommend discontinuation of chronic ibuprofen due to risk of intestinal inflammation. Patients may inquire about adjuvant cannabis in pain management. While cannabis can be considered, further research is needed to recommend its regular use.
 

Conclusion

Acute abdominal pain management in IBD can be challenging for providers when typical options are limited in this population. Addressing inflammatory, mechanical, neurobiological, and psychological influences is vital to appropriately address pain. Having a structured plan for pain management in IBD can improve outcomes by decreasing recurrent hospitalizations and use of opioids.¹⁵ Figure 2 presents an overview.

Courtesy Dr. Mehwish Ahmed and Dr. Jami Kinnucan

Dr. Ahmed is a second-year internal medicine resident at the University of Michigan, Ann Arbor. Dr. Kinnucan is with the department of internal medicine and the division of gastroenterology and hepatology and is an assistant professor of medicine in the division of gastroenterology, both at the University of Michigan. They have no conflicts of interest.

References

1. Burr NE et al. Clin Gastroenterol Hepatol. 2018 Apr;16(4):534-41.e6.

2. Takeuchi K et al. Clin Gastroenterol Hepatol. 2006 Feb;4(2):196-202.

3. Bernhofer EI et al. Gastroenterol Nurs. 2017 May/Jun;40(3):200-7.

4. Zeitz J et al. PLoS One. 2016 Jun 22;11(6):e0156666.

5. Srinath A et al. Inflamm Bowel Dis. 2014 Dec;20(12):2433-49.

6. Docherty MJ et al. Gastroenterol Hepatol (N Y). 2011 Sep;7(9):592-601.

7. Elsenbruch S et al. Gut. 2010 Apr;59(4):489-95.

8. Bernstein CN et al. Am J Gastroenterol. 2010 Sep;105(9):1994-2002.

9. Palsson OS and Whitehead WE. Clin Gastroenterol Hepatol. 2013 Mar;11(3):208-16; quiz e22-3.

10. Swaminath A et al. Inflamm Bowel Dis. 2019 Mar; 25(3):427-35.

11. Naftali T et al. Clin Gastroenterol Hepatol. 2013 Oct;11(10):1276-80.e1.

12. Sultan K and Swaminath A. J Crohns Colitis. 2020 Sep 16;14(9):1188-89.

13. Hirsch A et al. J Gastrointest Surg. 2015 Oct;19(10):1852-61.

14. Rogers MAM and Aronoff DM. Clin Microbiol Infect. 2016;22(2):178.e1-178.e9.

15. Kaimakliotis P et al. Int J Colorectal Dis. 2021 Jun;36(6):1193-200.
 

Clinical scenario

An 83-year-old man is admitted with a hemiplegic cerebrovascular accident. He is found to have dysphagia, and a nasogastric feeding tube is placed. Over the next several days, his strength begins to recover, and he tolerates his tube feeding well. Discharge to a skilled nursing facility (SNF) for subacute rehabilitation is planned. His swallowing is showing signs of recovery; it has not recovered adequately but is expected to continue to improve such that he is predicted to be independent of tube feeding within 7-14 days. None of the facilities in the region are willing to admit a patient with a nasal feeding tube, despite the anticipated short duration. The patient is medically ready for discharge but is refusing the feeding gastrostomy. “Why would I want a hole in my stomach, if I’m only going to need it for 1-2 weeks and this tube in my nose is working fine and is comfortable?” he pleads with tears in his eyes.

Feeding dysphagic patients after stroke

Dysphagia, potentially leading to aspiration and/or pneumonia, is a common sequela of stroke – up to half of hospitalized patients are affected.¹ When oral intake is contraindicated, patients are often fed by nasogastric tube (NGT) or by surgically or endoscopically placed gastrostomy tube (GT). Without good justification based on outcomes, NGTs are traditionally used when the need for feeding is thought to be short term (<4 weeks) and GTs are used for long term (>4 weeks). However, in 2005, a large multicenter randomized control trial found that the majority of stroke patients with dysphagia that would resolve had resolution within 2-3 weeks. Moreover, outcomes were equivalent or better for patients fed with an NGT versus GT.

The authors concluded by recommending feeding via NGT for 2-3 weeks, after which conversion to GT can be considered if dysphagia persists.¹ Notably, the recommendation allows consideration, and no evidence-based guideline requires or recommends GT be placed based on duration of tube feed dependence. Currently, while nutrition and neurology authorities have adopted these recommendations,^2,3 many authors have noted poor adherence to this guideline, and many find that the median period between stroke and GT placement is 7 days rather than the recommended minimum of 14.^4,5,6 While ignorance can partially explain the lack of widespread compliance,⁶ the policies of posthospital facilities are another culprit. Increasingly, and for a variety of reasons unsupported by the literature, SNFs refuse NGT and require GT.^4,7,8,9

Ethical considerations

The four principles of medical ethics – autonomy, beneficence, nonmaleficence, and justice – can guide clinicians, patients, and family members in decision-making. In our case, by withholding needed and desired treatment (discharge to and treatment by a rehabilitation facility) the patient is being coerced to undergo a procedure he does not want, and clinicians participate in denying him autonomy. Further, given that the evidence, national guidelines, and in fact federal regulations indicate that his preferences are congruent with best practices, pressuring him to accept gastrostomy placement runs afoul of the principles of beneficence and nonmaleficence. Though the mechanism is unclear, early gastrostomy (<14-21 days) is associated with increased risk of death, worse functional outcomes, and a lower rate of return to oral feeding, as well as a significant procedure-specific complication rate.^1,10 By insisting on gastrostomy, we neither act in this patient’s best interests nor “do no harm.”

However, the medical system is complex. The clinician at the bedside can evaluate this scenario, review the national guidelines, discuss the procedure and risks with the patient and family, and conclude that the patient should be discharged with a nasal feeding tube. Nevertheless, if no facility is willing to accept him without a gastrostomy, our decision-making model – previously limited to our patient’s best interests alone – is forced to change. Despite our misgivings, we often conclude that the harm done by an early gastrostomy is outweighed by the harm of remaining unnecessarily in the acute hospital setting. We further worry about other patients lingering in the emergency department for lack of an inpatient bed and the possible – though unknowable – harm done to them.
 

Looking forward

It is an unfortunate fact that medical decision-making must often include factors unrelated to the patient’s best interests, with financial considerations and structural barriers frequently driving deviation from ideal care. Providers and patients navigate these decisions to their best abilities, making compromises when forced. However, with education and professional activism, providers can advocate for the elimination of barriers to providing medically sound and ethically appropriate care. In our experience, delay of gastrostomy placement, until discharge is imminent and planning for postdischarge care is initiated, has resulted in a decrease by half the fraction of patients with tracheostomies who had gastrostomies placed prior to discharge.¹¹ With aggressive outreach and education, we now have nursing homes willing to accept patients with NGTs.

Criteria for admission to discharge facilities can drive medical decision-making that is unethical and unsupported by evidence. Continued efforts to eliminate barriers to appropriate and ethical care have been successful and are encouraged.
 

Dr. Cowan is administrative chief resident in the department of surgery at Columbia University Irving Medical Center, New York. Dr. Seres is professor of medicine in the Institute of Human Nutrition and associate clinical ethicist at Columbia University Irving Medical Center. The authors have no conflicts of interest to disclose.

References

1. Dennis MS et al. Lancet. 2005 Feb 26-Mar 4;365(9461):764-72.

2. Powers W. et al. Stroke. 2018 Mar;49(3):e46-e110.

3. Burgos R et al. Clin Nutr. 2018 Feb;37(1):354-96.

4. Wilmskoetter J et al. J Stroke Cerebrovasc Dis. 2016 Nov;25(11):2694-700.

5. George BP et al. Stroke. 2017 Feb;48(2):420-7.

6. Fessler TA. et al. Surg Endosc. 2019 Dec;33(12):4089-97.

7. Burgermaster M et al. Nutr Clin Pract. 2016 Jun;31(3):342-8.

8. Moran C and O’Mahoney S. Curr Opin Gastroenterol. 2015 Mar;31(2):137-42.

9. Gomes CA et al. Cochrane Database Syst Rev. 2010 Nov 10;(11):CD008096.

10. Joundi RA et al. Neurology. 2018 Feb 13;90(7):e544-52.

11. Bothra A et al. J Parenter Enteral Nutr. 2018 Feb;42(2):491.

Clinical scenario

An 83-year-old man is admitted with a hemiplegic cerebrovascular accident. He is found to have dysphagia, and a nasogastric feeding tube is placed. Over the next several days, his strength begins to recover, and he tolerates his tube feeding well. Discharge to a skilled nursing facility (SNF) for subacute rehabilitation is planned. His swallowing is showing signs of recovery; it has not recovered adequately but is expected to continue to improve such that he is predicted to be independent of tube feeding within 7-14 days. None of the facilities in the region are willing to admit a patient with a nasal feeding tube, despite the anticipated short duration. The patient is medically ready for discharge but is refusing the feeding gastrostomy. “Why would I want a hole in my stomach, if I’m only going to need it for 1-2 weeks and this tube in my nose is working fine and is comfortable?” he pleads with tears in his eyes.

Feeding dysphagic patients after stroke

Dysphagia, potentially leading to aspiration and/or pneumonia, is a common sequela of stroke – up to half of hospitalized patients are affected.¹ When oral intake is contraindicated, patients are often fed by nasogastric tube (NGT) or by surgically or endoscopically placed gastrostomy tube (GT). Without good justification based on outcomes, NGTs are traditionally used when the need for feeding is thought to be short term (<4 weeks) and GTs are used for long term (>4 weeks). However, in 2005, a large multicenter randomized control trial found that the majority of stroke patients with dysphagia that would resolve had resolution within 2-3 weeks. Moreover, outcomes were equivalent or better for patients fed with an NGT versus GT.

The authors concluded by recommending feeding via NGT for 2-3 weeks, after which conversion to GT can be considered if dysphagia persists.¹ Notably, the recommendation allows consideration, and no evidence-based guideline requires or recommends GT be placed based on duration of tube feed dependence. Currently, while nutrition and neurology authorities have adopted these recommendations,^2,3 many authors have noted poor adherence to this guideline, and many find that the median period between stroke and GT placement is 7 days rather than the recommended minimum of 14.^4,5,6 While ignorance can partially explain the lack of widespread compliance,⁶ the policies of posthospital facilities are another culprit. Increasingly, and for a variety of reasons unsupported by the literature, SNFs refuse NGT and require GT.^4,7,8,9

Ethical considerations

The four principles of medical ethics – autonomy, beneficence, nonmaleficence, and justice – can guide clinicians, patients, and family members in decision-making. In our case, by withholding needed and desired treatment (discharge to and treatment by a rehabilitation facility) the patient is being coerced to undergo a procedure he does not want, and clinicians participate in denying him autonomy. Further, given that the evidence, national guidelines, and in fact federal regulations indicate that his preferences are congruent with best practices, pressuring him to accept gastrostomy placement runs afoul of the principles of beneficence and nonmaleficence. Though the mechanism is unclear, early gastrostomy (<14-21 days) is associated with increased risk of death, worse functional outcomes, and a lower rate of return to oral feeding, as well as a significant procedure-specific complication rate.^1,10 By insisting on gastrostomy, we neither act in this patient’s best interests nor “do no harm.”

However, the medical system is complex. The clinician at the bedside can evaluate this scenario, review the national guidelines, discuss the procedure and risks with the patient and family, and conclude that the patient should be discharged with a nasal feeding tube. Nevertheless, if no facility is willing to accept him without a gastrostomy, our decision-making model – previously limited to our patient’s best interests alone – is forced to change. Despite our misgivings, we often conclude that the harm done by an early gastrostomy is outweighed by the harm of remaining unnecessarily in the acute hospital setting. We further worry about other patients lingering in the emergency department for lack of an inpatient bed and the possible – though unknowable – harm done to them.
 

Looking forward

It is an unfortunate fact that medical decision-making must often include factors unrelated to the patient’s best interests, with financial considerations and structural barriers frequently driving deviation from ideal care. Providers and patients navigate these decisions to their best abilities, making compromises when forced. However, with education and professional activism, providers can advocate for the elimination of barriers to providing medically sound and ethically appropriate care. In our experience, delay of gastrostomy placement, until discharge is imminent and planning for postdischarge care is initiated, has resulted in a decrease by half the fraction of patients with tracheostomies who had gastrostomies placed prior to discharge.¹¹ With aggressive outreach and education, we now have nursing homes willing to accept patients with NGTs.

Criteria for admission to discharge facilities can drive medical decision-making that is unethical and unsupported by evidence. Continued efforts to eliminate barriers to appropriate and ethical care have been successful and are encouraged.
 

Dr. Cowan is administrative chief resident in the department of surgery at Columbia University Irving Medical Center, New York. Dr. Seres is professor of medicine in the Institute of Human Nutrition and associate clinical ethicist at Columbia University Irving Medical Center. The authors have no conflicts of interest to disclose.

References

1. Dennis MS et al. Lancet. 2005 Feb 26-Mar 4;365(9461):764-72.

2. Powers W. et al. Stroke. 2018 Mar;49(3):e46-e110.

3. Burgos R et al. Clin Nutr. 2018 Feb;37(1):354-96.

4. Wilmskoetter J et al. J Stroke Cerebrovasc Dis. 2016 Nov;25(11):2694-700.

5. George BP et al. Stroke. 2017 Feb;48(2):420-7.

6. Fessler TA. et al. Surg Endosc. 2019 Dec;33(12):4089-97.

7. Burgermaster M et al. Nutr Clin Pract. 2016 Jun;31(3):342-8.

8. Moran C and O’Mahoney S. Curr Opin Gastroenterol. 2015 Mar;31(2):137-42.

9. Gomes CA et al. Cochrane Database Syst Rev. 2010 Nov 10;(11):CD008096.

10. Joundi RA et al. Neurology. 2018 Feb 13;90(7):e544-52.

11. Bothra A et al. J Parenter Enteral Nutr. 2018 Feb;42(2):491.

Clinical scenario

An 83-year-old man is admitted with a hemiplegic cerebrovascular accident. He is found to have dysphagia, and a nasogastric feeding tube is placed. Over the next several days, his strength begins to recover, and he tolerates his tube feeding well. Discharge to a skilled nursing facility (SNF) for subacute rehabilitation is planned. His swallowing is showing signs of recovery; it has not recovered adequately but is expected to continue to improve such that he is predicted to be independent of tube feeding within 7-14 days. None of the facilities in the region are willing to admit a patient with a nasal feeding tube, despite the anticipated short duration. The patient is medically ready for discharge but is refusing the feeding gastrostomy. “Why would I want a hole in my stomach, if I’m only going to need it for 1-2 weeks and this tube in my nose is working fine and is comfortable?” he pleads with tears in his eyes.

Feeding dysphagic patients after stroke

Dysphagia, potentially leading to aspiration and/or pneumonia, is a common sequela of stroke – up to half of hospitalized patients are affected.¹ When oral intake is contraindicated, patients are often fed by nasogastric tube (NGT) or by surgically or endoscopically placed gastrostomy tube (GT). Without good justification based on outcomes, NGTs are traditionally used when the need for feeding is thought to be short term (<4 weeks) and GTs are used for long term (>4 weeks). However, in 2005, a large multicenter randomized control trial found that the majority of stroke patients with dysphagia that would resolve had resolution within 2-3 weeks. Moreover, outcomes were equivalent or better for patients fed with an NGT versus GT.

The authors concluded by recommending feeding via NGT for 2-3 weeks, after which conversion to GT can be considered if dysphagia persists.¹ Notably, the recommendation allows consideration, and no evidence-based guideline requires or recommends GT be placed based on duration of tube feed dependence. Currently, while nutrition and neurology authorities have adopted these recommendations,^2,3 many authors have noted poor adherence to this guideline, and many find that the median period between stroke and GT placement is 7 days rather than the recommended minimum of 14.^4,5,6 While ignorance can partially explain the lack of widespread compliance,⁶ the policies of posthospital facilities are another culprit. Increasingly, and for a variety of reasons unsupported by the literature, SNFs refuse NGT and require GT.^4,7,8,9

Ethical considerations

The four principles of medical ethics – autonomy, beneficence, nonmaleficence, and justice – can guide clinicians, patients, and family members in decision-making. In our case, by withholding needed and desired treatment (discharge to and treatment by a rehabilitation facility) the patient is being coerced to undergo a procedure he does not want, and clinicians participate in denying him autonomy. Further, given that the evidence, national guidelines, and in fact federal regulations indicate that his preferences are congruent with best practices, pressuring him to accept gastrostomy placement runs afoul of the principles of beneficence and nonmaleficence. Though the mechanism is unclear, early gastrostomy (<14-21 days) is associated with increased risk of death, worse functional outcomes, and a lower rate of return to oral feeding, as well as a significant procedure-specific complication rate.^1,10 By insisting on gastrostomy, we neither act in this patient’s best interests nor “do no harm.”

However, the medical system is complex. The clinician at the bedside can evaluate this scenario, review the national guidelines, discuss the procedure and risks with the patient and family, and conclude that the patient should be discharged with a nasal feeding tube. Nevertheless, if no facility is willing to accept him without a gastrostomy, our decision-making model – previously limited to our patient’s best interests alone – is forced to change. Despite our misgivings, we often conclude that the harm done by an early gastrostomy is outweighed by the harm of remaining unnecessarily in the acute hospital setting. We further worry about other patients lingering in the emergency department for lack of an inpatient bed and the possible – though unknowable – harm done to them.
 

Looking forward

It is an unfortunate fact that medical decision-making must often include factors unrelated to the patient’s best interests, with financial considerations and structural barriers frequently driving deviation from ideal care. Providers and patients navigate these decisions to their best abilities, making compromises when forced. However, with education and professional activism, providers can advocate for the elimination of barriers to providing medically sound and ethically appropriate care. In our experience, delay of gastrostomy placement, until discharge is imminent and planning for postdischarge care is initiated, has resulted in a decrease by half the fraction of patients with tracheostomies who had gastrostomies placed prior to discharge.¹¹ With aggressive outreach and education, we now have nursing homes willing to accept patients with NGTs.

Criteria for admission to discharge facilities can drive medical decision-making that is unethical and unsupported by evidence. Continued efforts to eliminate barriers to appropriate and ethical care have been successful and are encouraged.
 

Dr. Cowan is administrative chief resident in the department of surgery at Columbia University Irving Medical Center, New York. Dr. Seres is professor of medicine in the Institute of Human Nutrition and associate clinical ethicist at Columbia University Irving Medical Center. The authors have no conflicts of interest to disclose.

References

1. Dennis MS et al. Lancet. 2005 Feb 26-Mar 4;365(9461):764-72.

2. Powers W. et al. Stroke. 2018 Mar;49(3):e46-e110.

3. Burgos R et al. Clin Nutr. 2018 Feb;37(1):354-96.

4. Wilmskoetter J et al. J Stroke Cerebrovasc Dis. 2016 Nov;25(11):2694-700.

5. George BP et al. Stroke. 2017 Feb;48(2):420-7.

6. Fessler TA. et al. Surg Endosc. 2019 Dec;33(12):4089-97.

7. Burgermaster M et al. Nutr Clin Pract. 2016 Jun;31(3):342-8.

8. Moran C and O’Mahoney S. Curr Opin Gastroenterol. 2015 Mar;31(2):137-42.

9. Gomes CA et al. Cochrane Database Syst Rev. 2010 Nov 10;(11):CD008096.

10. Joundi RA et al. Neurology. 2018 Feb 13;90(7):e544-52.

11. Bothra A et al. J Parenter Enteral Nutr. 2018 Feb;42(2):491.

The concept of home ownership has changed for this generation, not only in the logistics of the best way to do it, but also in the desire and demand for owning versus renting. According to the Penn Institute for Urban Research, the U.S. homeownership rate is now at 63.7%, the lowest in 48 years. “Homeownership rates have declined for all demographic age groups. Since 2006, the number of households who own their home in the United States has decreased by 674,000 while the number of renters has increased by over 8 million.”¹

But isn’t owning your own home the American dream? Isn’t it a great investment? If we’re looking strictly at the monthly payment numbers, traditionally paying a mortgage is cheaper than paying rent for the same-size home. That became even more true as home prices dropped in 2007-2008 and as interest rates also dropped over the last several years. Then there’s the age-old concept of “building equity” or “throwing away money on rent.” As a financial planner, I get asked all the time about a home as an investment. It certainly can be, like any investment, if you buy and sell at the right time. But something is only an investment if it grows, and you can’t predict if you’re going to buy and sell your house at the right time. The median price of an existing home sold in March 2021 was $329,100. That’s a 17.2% increase from March 2020. Times are certainly crazy right now in the real estate market.

What many people don’t think about are the other costs, and not just financial costs. Today’s generation is more aware of the added stress and burden of maintaining a home and the money you can sink into it for maintenance, let alone remodeling. Then of course there’s the mortgage interest, property taxes, and insurance that you won’t have with a rental. Lastly, the biggest reason today’s generation is choosing to rent more and more is the flexibility. They want to be more mobile, able to get up and move without having to worry about listing, selling, and possibly owing more than the house is worth, and being stuck. We saw this with many residents that bought a home during residency and then tried to sell when they landed their first job, only to find out they owed more than it was worth because of the real estate market collapse of 2008. Approximately 50% of physicians will leave their first job within 1-3 years, so it’s a gamble that you’ll be able to sell your house when you want to for the price you need.

But what are the benefits of buying? First, there is the age-old argument of building equity. If you stay in your house long enough, and plan to sell it when you retire and downsize, it can definitely be an investment. If you keep a mortgage long enough, eventually you’ll pay it off, and have no payment. Mortgage interest is also tax-deductible. Lastly, there are the intangibles – like being able to put down roots, build a community, and have the ability to remodel and customize your home, a feature not usually available when renting.

Now that I’ve effectively talked you out and back in again, what’s the best way to go about buying a house in today’s crazy market? We’ve seen houses list and sell within a day and get multiple offers well over asking price. It’s a very difficult time to buy, but there are ways to make it easier. First, be clear on what you want in a house, especially location. There’s nothing worse than buyer’s remorse in your primary residence, and that happens more these days when people have to quickly make a decision. Find a good, fee-based financial planner to help you decide how much house fits in your budget and your long-term goals. You’d be surprised how easily we can talk ourselves into paying much more than we had originally decided. Use your financial planner to help avoid emotions getting involved and creeping up your price (especially when multiple offers are involved). A good rule of thumb is for a housing payment to be no more than 33% of your take-home income. This includes principal, interest, and taxes. Or, many planners will use the “2x income” rule of thumb. So if you make $300,000, don’t go over $600,000. Although with today’s low interest rates, there is some more wiggle room on that. Next, get a good referral from someone you trust in looking for a realtor. Real estate is a commission-based job and can have some potential conflicts of interest, so getting a recommendation can help. Or, there are realtors who will work for a flat fee, regardless of how much you pay for a house. That can help reduce the conflict.

You made the offer, you beat out the other bids, and you’re getting a house! How are you paying for it? Hopefully, you already got preapproved. This means finding a good, reputable mortgage professional. Get referrals, shop around, and take your time. Get multiple quotes before you start the underwriting process. They shouldn’t have to pull your credit to give you a fairly accurate estimate of what interest rate you’ll qualify for. Usually, they will give you fixed and variable interest quotes. I normally recommend fixed interest. Because interest rates are so low right now, they’re only going to go up in the future, and if you have a variable rate loan, your payment will go up as interest rates rise.

Is a physician loan a good idea? Depending on your circumstance, it can often be a good deal. Most new attendings don’t have cash saved up for a down payment, and these often don’t require one. And the other big benefit is that they won’t consider your student loan payments when calculating your debt-to-income ratio. Mortgage lenders will look at how much other debt you have when determining an approval. And a conventional mortgage will take your student loan payments into consideration, which means you’ll qualify for a much lower payment and purchase price. In my experience, you want a credit score of around 700 or higher to qualify for these types of loans. The only downside of a physician mortgage is the rates are slightly higher. I encourage you to start the application process early; they’re taking upward of 90 days lately.

As the mortgage is being processed, you’ll have an inspection and appraisal, and as long as those are all favorable, you’re in! Now, should you take any surplus income each month and pay extra on your mortgage to pay it down sooner, or invest it? Everyone’s situation is different, but a good rule of thumb is to look at interest rates on the debt you want to pay off versus expected rate of return on the potential investment. For example, if you have extra money, should you invest it in an SP500 index fund that historically gets 8%-12% per year, or put it on the principal of your mortgage that has an interest rate of 3%? Assuming no other factors or goals, and you just want the best bang for your buck, my money would go toward the investment getting 8%-12% over saving 3% on my mortgage.

Take your time, do your research, and find good professionals. There’s no right answer for everyone, but there are certainly some good practices when walking through the first home decision. Here at FinancialMD, we only work with physicians, and we’re happy to chat if you want some guidance on this. Send me an email and subscribe to our weekly Didactic Minute videos on YouTube for more financial tips for young physicians. Good luck!

Mr. Solitro is a financial planner and CEO of FinancialMD. He has no other conflicts of interest.

Investment advisory services offered through FinancialMD, a registered investment adviser. Registration as an investment adviser does not imply a certain level of skill or training. This article is provided for informational purposes only and nothing contained herein should be construed as a solicitation to buy or sell any products. Advisory services are offered only to clients and prospective clients in places where FinancialMD and its investment adviser representatives are registered or exempt from registration. Investing involves the risk of loss of principal. Past performance is no guarantee of future performance and no investment strategy can guarantee a profit or protect against loss.

This article was updated June 8, 2021.

Reference

1. Wachter S and Acolin A. Owning or Renting in the US: Shifting Dynamics of the Housing Market. Penn Institute for Urban Research. 2016 May.

The concept of home ownership has changed for this generation, not only in the logistics of the best way to do it, but also in the desire and demand for owning versus renting. According to the Penn Institute for Urban Research, the U.S. homeownership rate is now at 63.7%, the lowest in 48 years. “Homeownership rates have declined for all demographic age groups. Since 2006, the number of households who own their home in the United States has decreased by 674,000 while the number of renters has increased by over 8 million.”¹

But isn’t owning your own home the American dream? Isn’t it a great investment? If we’re looking strictly at the monthly payment numbers, traditionally paying a mortgage is cheaper than paying rent for the same-size home. That became even more true as home prices dropped in 2007-2008 and as interest rates also dropped over the last several years. Then there’s the age-old concept of “building equity” or “throwing away money on rent.” As a financial planner, I get asked all the time about a home as an investment. It certainly can be, like any investment, if you buy and sell at the right time. But something is only an investment if it grows, and you can’t predict if you’re going to buy and sell your house at the right time. The median price of an existing home sold in March 2021 was $329,100. That’s a 17.2% increase from March 2020. Times are certainly crazy right now in the real estate market.

What many people don’t think about are the other costs, and not just financial costs. Today’s generation is more aware of the added stress and burden of maintaining a home and the money you can sink into it for maintenance, let alone remodeling. Then of course there’s the mortgage interest, property taxes, and insurance that you won’t have with a rental. Lastly, the biggest reason today’s generation is choosing to rent more and more is the flexibility. They want to be more mobile, able to get up and move without having to worry about listing, selling, and possibly owing more than the house is worth, and being stuck. We saw this with many residents that bought a home during residency and then tried to sell when they landed their first job, only to find out they owed more than it was worth because of the real estate market collapse of 2008. Approximately 50% of physicians will leave their first job within 1-3 years, so it’s a gamble that you’ll be able to sell your house when you want to for the price you need.

But what are the benefits of buying? First, there is the age-old argument of building equity. If you stay in your house long enough, and plan to sell it when you retire and downsize, it can definitely be an investment. If you keep a mortgage long enough, eventually you’ll pay it off, and have no payment. Mortgage interest is also tax-deductible. Lastly, there are the intangibles – like being able to put down roots, build a community, and have the ability to remodel and customize your home, a feature not usually available when renting.

Now that I’ve effectively talked you out and back in again, what’s the best way to go about buying a house in today’s crazy market? We’ve seen houses list and sell within a day and get multiple offers well over asking price. It’s a very difficult time to buy, but there are ways to make it easier. First, be clear on what you want in a house, especially location. There’s nothing worse than buyer’s remorse in your primary residence, and that happens more these days when people have to quickly make a decision. Find a good, fee-based financial planner to help you decide how much house fits in your budget and your long-term goals. You’d be surprised how easily we can talk ourselves into paying much more than we had originally decided. Use your financial planner to help avoid emotions getting involved and creeping up your price (especially when multiple offers are involved). A good rule of thumb is for a housing payment to be no more than 33% of your take-home income. This includes principal, interest, and taxes. Or, many planners will use the “2x income” rule of thumb. So if you make $300,000, don’t go over $600,000. Although with today’s low interest rates, there is some more wiggle room on that. Next, get a good referral from someone you trust in looking for a realtor. Real estate is a commission-based job and can have some potential conflicts of interest, so getting a recommendation can help. Or, there are realtors who will work for a flat fee, regardless of how much you pay for a house. That can help reduce the conflict.

You made the offer, you beat out the other bids, and you’re getting a house! How are you paying for it? Hopefully, you already got preapproved. This means finding a good, reputable mortgage professional. Get referrals, shop around, and take your time. Get multiple quotes before you start the underwriting process. They shouldn’t have to pull your credit to give you a fairly accurate estimate of what interest rate you’ll qualify for. Usually, they will give you fixed and variable interest quotes. I normally recommend fixed interest. Because interest rates are so low right now, they’re only going to go up in the future, and if you have a variable rate loan, your payment will go up as interest rates rise.

Is a physician loan a good idea? Depending on your circumstance, it can often be a good deal. Most new attendings don’t have cash saved up for a down payment, and these often don’t require one. And the other big benefit is that they won’t consider your student loan payments when calculating your debt-to-income ratio. Mortgage lenders will look at how much other debt you have when determining an approval. And a conventional mortgage will take your student loan payments into consideration, which means you’ll qualify for a much lower payment and purchase price. In my experience, you want a credit score of around 700 or higher to qualify for these types of loans. The only downside of a physician mortgage is the rates are slightly higher. I encourage you to start the application process early; they’re taking upward of 90 days lately.

As the mortgage is being processed, you’ll have an inspection and appraisal, and as long as those are all favorable, you’re in! Now, should you take any surplus income each month and pay extra on your mortgage to pay it down sooner, or invest it? Everyone’s situation is different, but a good rule of thumb is to look at interest rates on the debt you want to pay off versus expected rate of return on the potential investment. For example, if you have extra money, should you invest it in an SP500 index fund that historically gets 8%-12% per year, or put it on the principal of your mortgage that has an interest rate of 3%? Assuming no other factors or goals, and you just want the best bang for your buck, my money would go toward the investment getting 8%-12% over saving 3% on my mortgage.

Take your time, do your research, and find good professionals. There’s no right answer for everyone, but there are certainly some good practices when walking through the first home decision. Here at FinancialMD, we only work with physicians, and we’re happy to chat if you want some guidance on this. Send me an email and subscribe to our weekly Didactic Minute videos on YouTube for more financial tips for young physicians. Good luck!

Mr. Solitro is a financial planner and CEO of FinancialMD. He has no other conflicts of interest.

Investment advisory services offered through FinancialMD, a registered investment adviser. Registration as an investment adviser does not imply a certain level of skill or training. This article is provided for informational purposes only and nothing contained herein should be construed as a solicitation to buy or sell any products. Advisory services are offered only to clients and prospective clients in places where FinancialMD and its investment adviser representatives are registered or exempt from registration. Investing involves the risk of loss of principal. Past performance is no guarantee of future performance and no investment strategy can guarantee a profit or protect against loss.

This article was updated June 8, 2021.

Reference

1. Wachter S and Acolin A. Owning or Renting in the US: Shifting Dynamics of the Housing Market. Penn Institute for Urban Research. 2016 May.

The concept of home ownership has changed for this generation, not only in the logistics of the best way to do it, but also in the desire and demand for owning versus renting. According to the Penn Institute for Urban Research, the U.S. homeownership rate is now at 63.7%, the lowest in 48 years. “Homeownership rates have declined for all demographic age groups. Since 2006, the number of households who own their home in the United States has decreased by 674,000 while the number of renters has increased by over 8 million.”¹

But isn’t owning your own home the American dream? Isn’t it a great investment? If we’re looking strictly at the monthly payment numbers, traditionally paying a mortgage is cheaper than paying rent for the same-size home. That became even more true as home prices dropped in 2007-2008 and as interest rates also dropped over the last several years. Then there’s the age-old concept of “building equity” or “throwing away money on rent.” As a financial planner, I get asked all the time about a home as an investment. It certainly can be, like any investment, if you buy and sell at the right time. But something is only an investment if it grows, and you can’t predict if you’re going to buy and sell your house at the right time. The median price of an existing home sold in March 2021 was $329,100. That’s a 17.2% increase from March 2020. Times are certainly crazy right now in the real estate market.

What many people don’t think about are the other costs, and not just financial costs. Today’s generation is more aware of the added stress and burden of maintaining a home and the money you can sink into it for maintenance, let alone remodeling. Then of course there’s the mortgage interest, property taxes, and insurance that you won’t have with a rental. Lastly, the biggest reason today’s generation is choosing to rent more and more is the flexibility. They want to be more mobile, able to get up and move without having to worry about listing, selling, and possibly owing more than the house is worth, and being stuck. We saw this with many residents that bought a home during residency and then tried to sell when they landed their first job, only to find out they owed more than it was worth because of the real estate market collapse of 2008. Approximately 50% of physicians will leave their first job within 1-3 years, so it’s a gamble that you’ll be able to sell your house when you want to for the price you need.

But what are the benefits of buying? First, there is the age-old argument of building equity. If you stay in your house long enough, and plan to sell it when you retire and downsize, it can definitely be an investment. If you keep a mortgage long enough, eventually you’ll pay it off, and have no payment. Mortgage interest is also tax-deductible. Lastly, there are the intangibles – like being able to put down roots, build a community, and have the ability to remodel and customize your home, a feature not usually available when renting.

Now that I’ve effectively talked you out and back in again, what’s the best way to go about buying a house in today’s crazy market? We’ve seen houses list and sell within a day and get multiple offers well over asking price. It’s a very difficult time to buy, but there are ways to make it easier. First, be clear on what you want in a house, especially location. There’s nothing worse than buyer’s remorse in your primary residence, and that happens more these days when people have to quickly make a decision. Find a good, fee-based financial planner to help you decide how much house fits in your budget and your long-term goals. You’d be surprised how easily we can talk ourselves into paying much more than we had originally decided. Use your financial planner to help avoid emotions getting involved and creeping up your price (especially when multiple offers are involved). A good rule of thumb is for a housing payment to be no more than 33% of your take-home income. This includes principal, interest, and taxes. Or, many planners will use the “2x income” rule of thumb. So if you make $300,000, don’t go over $600,000. Although with today’s low interest rates, there is some more wiggle room on that. Next, get a good referral from someone you trust in looking for a realtor. Real estate is a commission-based job and can have some potential conflicts of interest, so getting a recommendation can help. Or, there are realtors who will work for a flat fee, regardless of how much you pay for a house. That can help reduce the conflict.

You made the offer, you beat out the other bids, and you’re getting a house! How are you paying for it? Hopefully, you already got preapproved. This means finding a good, reputable mortgage professional. Get referrals, shop around, and take your time. Get multiple quotes before you start the underwriting process. They shouldn’t have to pull your credit to give you a fairly accurate estimate of what interest rate you’ll qualify for. Usually, they will give you fixed and variable interest quotes. I normally recommend fixed interest. Because interest rates are so low right now, they’re only going to go up in the future, and if you have a variable rate loan, your payment will go up as interest rates rise.

Is a physician loan a good idea? Depending on your circumstance, it can often be a good deal. Most new attendings don’t have cash saved up for a down payment, and these often don’t require one. And the other big benefit is that they won’t consider your student loan payments when calculating your debt-to-income ratio. Mortgage lenders will look at how much other debt you have when determining an approval. And a conventional mortgage will take your student loan payments into consideration, which means you’ll qualify for a much lower payment and purchase price. In my experience, you want a credit score of around 700 or higher to qualify for these types of loans. The only downside of a physician mortgage is the rates are slightly higher. I encourage you to start the application process early; they’re taking upward of 90 days lately.

As the mortgage is being processed, you’ll have an inspection and appraisal, and as long as those are all favorable, you’re in! Now, should you take any surplus income each month and pay extra on your mortgage to pay it down sooner, or invest it? Everyone’s situation is different, but a good rule of thumb is to look at interest rates on the debt you want to pay off versus expected rate of return on the potential investment. For example, if you have extra money, should you invest it in an SP500 index fund that historically gets 8%-12% per year, or put it on the principal of your mortgage that has an interest rate of 3%? Assuming no other factors or goals, and you just want the best bang for your buck, my money would go toward the investment getting 8%-12% over saving 3% on my mortgage.

Take your time, do your research, and find good professionals. There’s no right answer for everyone, but there are certainly some good practices when walking through the first home decision. Here at FinancialMD, we only work with physicians, and we’re happy to chat if you want some guidance on this. Send me an email and subscribe to our weekly Didactic Minute videos on YouTube for more financial tips for young physicians. Good luck!

Mr. Solitro is a financial planner and CEO of FinancialMD. He has no other conflicts of interest.

Investment advisory services offered through FinancialMD, a registered investment adviser. Registration as an investment adviser does not imply a certain level of skill or training. This article is provided for informational purposes only and nothing contained herein should be construed as a solicitation to buy or sell any products. Advisory services are offered only to clients and prospective clients in places where FinancialMD and its investment adviser representatives are registered or exempt from registration. Investing involves the risk of loss of principal. Past performance is no guarantee of future performance and no investment strategy can guarantee a profit or protect against loss.

This article was updated June 8, 2021.

Reference

1. Wachter S and Acolin A. Owning or Renting in the US: Shifting Dynamics of the Housing Market. Penn Institute for Urban Research. 2016 May.

Dear colleagues,

Welcome to the May edition of The New Gastroenterologist, which is packed with a fantastic line-up of articles! The 1-year mark of the pandemic recently passed, and we now are gearing up for our second virtual Digestive Disease Week (DDW®). While we are all anxious to return to lives that have some semblance of normalcy, we continue to endure the ebbs and flows that characterize life in a pandemic. For over a year now, we spend our days caught in a constant battle between the risk and reward of activities we previously took for granted or considered mundane. Our moods vacillate with the continued rise and fall of COVID-19 cases, but the advent and distribution of vaccines have offered palpable hope for better outcomes.

I’m pleased to introduce this quarter’s content – beginning with our legal section. Dr. John Azizian (UCLA-Olive-View), Dr. James Tabibian (UCLA-Olive-View), Dr. Camellia Dalai (UCLA-Olive-View/University of New Mexico), and Dr. Megan Adams (University of Michigan) contribute a comprehensive piece on medical professional liability (MPL), a topic that is seldom discussed in training but has important implications in clinical practice. This article reviews basic legal concepts, recent trends and details on gastroenterology specific claims, and most importantly, advice on how to mitigate MPL risk as gastroenterologists.

Many trainees and early career gastroenterologists face microaggressions for a variety of different reasons. Dr. Oveia Aktopaire and Dr. Rachel Issaka (University of Washington) present a thought-provoking piece as they delve into structural racism in medicine and how microaggressions are a proxy for bias.

Dyssynergic defecation (DD) affects up to one-half of patients with chronic constipation. The “In Focus” feature for May provides an excellent review of DD written by international expert Dr. Satish Rao and Dr. Asad Jehangir (both, Medical College of Georgia/Augusta University). The article provides guidance on the diagnosis of DD, including high-yield features of physical and digital rectal exams, guidance on interpretation of anorectal manometry testing, and how these can dictate an effective therapeutic plan.

Meaningful mentorship is crucial for young gastroenterologists but at times the nature of the mentor-mentee relationship can be difficult to navigate. Dr. David Fessell and Bridger Rodoni (University of Michigan) explore this dynamic and discuss the notion of mentorship malpractice in a compelling addition to our ethics case series.

Abdominal wall pain is common yet often overlooked diagnosis and a great teaching point for trainees. Dr. Manish Singla (Uniformed Services University/Capital Digestive Care) and Dr. Brian Park (Naval Medical Center) discuss the diagnosis and management and how the early recognition of abdominal wall pain can save both patients and clinicians from a battery of unnecessary diagnostic testing.

The DHPA Private Practice Perspectives article this quarter, written by Dr. Aja McCutchen (Atlanta Gastroenterology Associates), addresses colorectal cancer screening, the disparities that exist, and the important role we have as gastroenterologists in reducing barriers to screening. Lastly, Dr. Bilal Asif (University of Maryland/National Institutes of Health) walks us through a fellow’s perspective on the AGA’s first virtual Advocacy Day – demonstrating that advocacy is still possible even as a trainee and in the setting of a pandemic.

If you have interest in contributing or have ideas for future TNG topics, please contact me ([email protected]) or Ryan Farrell ([email protected]), managing editor of TNG.

Stay well,

Vijaya L. Rao, MD
Editor in Chief
Assistant Professor of Medicine, University of Chicago, Section of Gastroenterology, Hepatology & Nutrition

Dear colleagues,

Welcome to the May edition of The New Gastroenterologist, which is packed with a fantastic line-up of articles! The 1-year mark of the pandemic recently passed, and we now are gearing up for our second virtual Digestive Disease Week (DDW®). While we are all anxious to return to lives that have some semblance of normalcy, we continue to endure the ebbs and flows that characterize life in a pandemic. For over a year now, we spend our days caught in a constant battle between the risk and reward of activities we previously took for granted or considered mundane. Our moods vacillate with the continued rise and fall of COVID-19 cases, but the advent and distribution of vaccines have offered palpable hope for better outcomes.

I’m pleased to introduce this quarter’s content – beginning with our legal section. Dr. John Azizian (UCLA-Olive-View), Dr. James Tabibian (UCLA-Olive-View), Dr. Camellia Dalai (UCLA-Olive-View/University of New Mexico), and Dr. Megan Adams (University of Michigan) contribute a comprehensive piece on medical professional liability (MPL), a topic that is seldom discussed in training but has important implications in clinical practice. This article reviews basic legal concepts, recent trends and details on gastroenterology specific claims, and most importantly, advice on how to mitigate MPL risk as gastroenterologists.

Many trainees and early career gastroenterologists face microaggressions for a variety of different reasons. Dr. Oveia Aktopaire and Dr. Rachel Issaka (University of Washington) present a thought-provoking piece as they delve into structural racism in medicine and how microaggressions are a proxy for bias.

Dyssynergic defecation (DD) affects up to one-half of patients with chronic constipation. The “In Focus” feature for May provides an excellent review of DD written by international expert Dr. Satish Rao and Dr. Asad Jehangir (both, Medical College of Georgia/Augusta University). The article provides guidance on the diagnosis of DD, including high-yield features of physical and digital rectal exams, guidance on interpretation of anorectal manometry testing, and how these can dictate an effective therapeutic plan.

Meaningful mentorship is crucial for young gastroenterologists but at times the nature of the mentor-mentee relationship can be difficult to navigate. Dr. David Fessell and Bridger Rodoni (University of Michigan) explore this dynamic and discuss the notion of mentorship malpractice in a compelling addition to our ethics case series.

Abdominal wall pain is common yet often overlooked diagnosis and a great teaching point for trainees. Dr. Manish Singla (Uniformed Services University/Capital Digestive Care) and Dr. Brian Park (Naval Medical Center) discuss the diagnosis and management and how the early recognition of abdominal wall pain can save both patients and clinicians from a battery of unnecessary diagnostic testing.

The DHPA Private Practice Perspectives article this quarter, written by Dr. Aja McCutchen (Atlanta Gastroenterology Associates), addresses colorectal cancer screening, the disparities that exist, and the important role we have as gastroenterologists in reducing barriers to screening. Lastly, Dr. Bilal Asif (University of Maryland/National Institutes of Health) walks us through a fellow’s perspective on the AGA’s first virtual Advocacy Day – demonstrating that advocacy is still possible even as a trainee and in the setting of a pandemic.

If you have interest in contributing or have ideas for future TNG topics, please contact me ([email protected]) or Ryan Farrell ([email protected]), managing editor of TNG.

Stay well,

Vijaya L. Rao, MD
Editor in Chief
Assistant Professor of Medicine, University of Chicago, Section of Gastroenterology, Hepatology & Nutrition

Dear colleagues,

Welcome to the May edition of The New Gastroenterologist, which is packed with a fantastic line-up of articles! The 1-year mark of the pandemic recently passed, and we now are gearing up for our second virtual Digestive Disease Week (DDW®). While we are all anxious to return to lives that have some semblance of normalcy, we continue to endure the ebbs and flows that characterize life in a pandemic. For over a year now, we spend our days caught in a constant battle between the risk and reward of activities we previously took for granted or considered mundane. Our moods vacillate with the continued rise and fall of COVID-19 cases, but the advent and distribution of vaccines have offered palpable hope for better outcomes.

I’m pleased to introduce this quarter’s content – beginning with our legal section. Dr. John Azizian (UCLA-Olive-View), Dr. James Tabibian (UCLA-Olive-View), Dr. Camellia Dalai (UCLA-Olive-View/University of New Mexico), and Dr. Megan Adams (University of Michigan) contribute a comprehensive piece on medical professional liability (MPL), a topic that is seldom discussed in training but has important implications in clinical practice. This article reviews basic legal concepts, recent trends and details on gastroenterology specific claims, and most importantly, advice on how to mitigate MPL risk as gastroenterologists.

Many trainees and early career gastroenterologists face microaggressions for a variety of different reasons. Dr. Oveia Aktopaire and Dr. Rachel Issaka (University of Washington) present a thought-provoking piece as they delve into structural racism in medicine and how microaggressions are a proxy for bias.

Dyssynergic defecation (DD) affects up to one-half of patients with chronic constipation. The “In Focus” feature for May provides an excellent review of DD written by international expert Dr. Satish Rao and Dr. Asad Jehangir (both, Medical College of Georgia/Augusta University). The article provides guidance on the diagnosis of DD, including high-yield features of physical and digital rectal exams, guidance on interpretation of anorectal manometry testing, and how these can dictate an effective therapeutic plan.

Meaningful mentorship is crucial for young gastroenterologists but at times the nature of the mentor-mentee relationship can be difficult to navigate. Dr. David Fessell and Bridger Rodoni (University of Michigan) explore this dynamic and discuss the notion of mentorship malpractice in a compelling addition to our ethics case series.

Abdominal wall pain is common yet often overlooked diagnosis and a great teaching point for trainees. Dr. Manish Singla (Uniformed Services University/Capital Digestive Care) and Dr. Brian Park (Naval Medical Center) discuss the diagnosis and management and how the early recognition of abdominal wall pain can save both patients and clinicians from a battery of unnecessary diagnostic testing.

The DHPA Private Practice Perspectives article this quarter, written by Dr. Aja McCutchen (Atlanta Gastroenterology Associates), addresses colorectal cancer screening, the disparities that exist, and the important role we have as gastroenterologists in reducing barriers to screening. Lastly, Dr. Bilal Asif (University of Maryland/National Institutes of Health) walks us through a fellow’s perspective on the AGA’s first virtual Advocacy Day – demonstrating that advocacy is still possible even as a trainee and in the setting of a pandemic.

If you have interest in contributing or have ideas for future TNG topics, please contact me ([email protected]) or Ryan Farrell ([email protected]), managing editor of TNG.

Stay well,

Vijaya L. Rao, MD
Editor in Chief
Assistant Professor of Medicine, University of Chicago, Section of Gastroenterology, Hepatology & Nutrition

Introduction

About 40% of the population experiences lower GI symptoms suggestive of gastrointestinal motility disorders.^1,2 The global prevalence of chronic constipation is 18%, and the condition includes multiple overlapping subtypes.³ Evacuation disorders affect over half (59%) of patients and include dyssynergic defecation (DD).⁴ The inability to coordinate the abdominal, rectal, pelvic floor, and anal/puborectalis muscles to evacuate stools causes DD.⁵ The etiology of DD remains unclear and is often misdiagnosed. Clinically, the symptoms of DD overlap with other lower GI disorders, often leading to unnecessary and invasive procedures.² We describe the clinical characteristics, diagnostic tools, treatment options, and evidence-based approach for the management of DD.

Vidyard Video

Clinical presentation

Over two-thirds of patients with DD acquire this disorder during adulthood, and one-third have symptoms from childhood.⁶ Though there is not usually an inciting event, 29% of patients report that symptoms began after events such as pregnancy or back injury,⁶ and opioid users have higher prevalence and severity of DD.⁷

Over 80% of patients report excessive straining, feelings of incomplete evacuation, and hard stools, and 50% report sensation of anal blockage or use of digital maneuvers.² Other symptoms include infrequent bowel movements, abdominal pain, anal pain, and stool leakage.² Evaluation of DD includes obtaining a detailed history utilizing the Bristol Stool Form Scale;⁸ however, patients’ recall of stool habit is often inaccurate, which results in suboptimal care.^9,10 Prospective stool diaries can help to provide more objective assessment of patients’ symptoms, eliminate recall bias, and provide more reliable information. Several useful questionnaires are available for clinical and research purposes to characterize lower-GI symptoms, including the Constipation Scoring System,¹¹ Patient Assessment of Constipation Symptoms (PAC-SYM),¹² and Patient Assessment of Constipation Quality of Life (PAC-QOL).^2,13 The Constipation Stool digital app enhances accuracy of data capture and offers a reliable and user-friendly method for recording bowel symptoms for patients, clinicians, and clinical investigators.¹⁴

 

Diagnosis

The diagnosis of DD requires careful physical and digital rectal examination together with anorectal manometry and a balloon expulsion test. Defecography and colonic transit studies provide additional assessment.

Physical examination

Abdominal examination should include palpation for stool in the colon and identification of abdominal mass or fecal impaction.²A high-quality digital rectal examination can help to identify patients who could benefit from physiological testing to confirm and treat DD.¹⁵ Rectal examination is performed by placing examiner’s lubricated gloved right index finger in a patient’s rectum, with the examiner’s left hand on patient’s abdomen, and asking the patient to push and bear down as if defecating.¹⁵ The contraction of the abdominal muscles is felt using the left hand, while the anal sphincter relaxation and degree of perineal descent are felt using the right-hand index finger.¹⁵ A diagnosis of dyssynergia is suspected if the digital rectal examination reveals two or more of the following abnormalities: inability to contract abdominal muscles (lack of push effort), inability to relax or paradoxical contraction of the anal sphincter and/or puborectalis, or absence of perineal descent.¹⁵ Digital rectal examination has good sensitivity (75%), specificity (87%), and positive predictive value (97%) for DD.¹⁶

 

 

High resolution anorectal manometry

Anorectal manometry (ARM) is the preferred method for the evaluation of defecatory disorders.^17,18 ARM is best performed using the high-resolution anorectal manometry (HRAM) systems¹⁹ that consist of a flexible probe – 0.5-cm diameter with multiple circumferential sensors along the anal canal – and another two sensors inside a rectal balloon.¹⁸ It provides a topographic and waveform display of manometric pressure data (Figure). The 3D high-definition ARM probe is a rigid 1-cm probe that provides 3D topographic profiles.¹⁸ ARM is typically performed in both the left lateral position and in a more physiological seated position.^20,21 There is considerable variation amongst different institutions on how to perform HRAM, and a recent International Anorectal Physiology Working Group (IAPWG) has provided consensus recommendations for performing this test.²² The procedure for performing HRAM is reviewed elsewhere, but the key elements are summarized below.¹⁸

Push maneuver: On HRAM, after the assessment of resting and squeeze anal sphincter pressures, the patient is asked to push or bear down as if to defecate while lying in left lateral decubitus position. The best of two attempts that closely mimics a normal bearing down maneuver is used for categorizing patient’s defecatory pattern.¹⁸ In patients with DD, at least four distinct dyssynergia phenotypes have been recognized (Figure),²³ though recent studies suggest eight patterns.²⁴ Defecation index (maximum rectal pressure/minimum residual anal pressure when bearing down) greater than 1.2 is considered normal.¹⁸

Simulated defecation on commode: The subject is asked to attempt defecation while seated on a commode with intrarectal balloon filled with 60 cc of air, and both the defecation pattern(s) and defecation index are calculated. A lack of coordinated push effort is highly suggestive of DD.²¹

Rectoanal Inhibitory Reflex (RAIR): RAIR describes the reflex relaxation of the internal anal sphincter after rectal distension. RAIR is dependent on intact autonomic ganglia and myenteric plexus²⁵and is mediated by the release of nitric oxide and vasoactive intestinal peptide.²⁶ The absence of RAIR suggests Hirschsprung disease.^22.27.28

Rectal sensory testing: Intermittent balloon distension of the rectum with incremental volumes of air induces a range of rectal sensations that include first sensation, desire to defecate, urgency to defecate, and maximum tolerable volume. Rectal hyposensitivity is diagnosed when two or more sensory thresholds are higher than those seen in normal subjects^29.30 and likely results from disruption of afferent gut-brain pathways, cortical perception/rectal wall dysfunction, or both.²⁹ Rectal hyposensitivity affects 40% of patients with constipation³⁰and is associated with DD but not delayed colonic transit.³¹ Rectal hyposensitivity may also be seen in patients with diabetes or fecal incontinence.¹⁸ About two-thirds of patients with rectal hyposensitivity have rectal hypercompliance, and some have megarectum.³² Some patients with DD have coexisting irritable bowel syndrome (IBS) and may have rectal hypersensitivity.^18,33 Rectal compliance is measured alongside rectal sensitivity analysis by plotting a graph between the change in intraballoon volume (mL) and change in intrarectal pressures (mm Hg) during incremental balloon distensions.^18.34 Rectal hypercompliance may be seen in megarectum and dyssynergic defecation.^34,35 Rectal hypocompliance may be seen in patients with inflammatory bowel disease, postpelvic radiation, chronic ischemia, and advanced age.¹⁸

Balloon expulsion test: This test is performed by placing a plastic probe with a balloon in the rectum and filling it with 50 cc of warm water. Patients are given 5 minutes to expel the balloon while sitting on a commode. Balloon expulsion time of more than 1 minute suggests a diagnosis of DD,²¹ although 2 minutes provides a higher level of agreement with manometric findings.³⁶ Balloon type and body position can influence the results.³⁷ Inability to expel the balloon with normal manometric findings is considered an inconclusive finding per the recent London Classification (i.e., it may be associated with generation of anorectal symptoms, but the clinical relevance of this finding is unclear as it may also be seen in healthy subjects).²²

 

 

Defecography

Defecography is a dynamic fluoroscopic study performed in the sitting position after injecting 150 mL of barium paste into the patient’s rectum. Defecography provides useful information about structural changes (e.g., rectoceles, enteroceles, rectal prolapse, and intussusception), DD, and descending perineum syndrome.³⁸ Methodological differences, radiation exposure, and poor interobserver agreement have limited its wider use; therefore, anorectal manometry and the balloon expulsion test are recommended for the initial evaluation of DD.³⁹ Magnetic resonance defecography may be more useful.^17,38

Colonic transit studies

Colonic transit study can be assessed using radiopaque markers, wireless motility capsule, or scintigraphy. Wireless motility capsule and scintigraphy have the advantage of determining gastric, small bowel, and whole gut transit times as well. About two-thirds of patients with DD have slow transit constipation (STC),⁶ which improves after treatment of DD.⁴⁰ Hence, in patients with chronic constipation, evaluation and management of DD is recommended first. If symptoms persist, then consider colonic transit assessment.⁴¹ Given the overlapping nature of the conditions, documentation of STC at the outset could facilitate treatment of both.

Diagnostic criteria for DD

Patients should fulfill the following criteria for diagnosis of DD:^42,43

• Fulfill symptom(s) diagnostic criteria for functional constipation and/or constipation-predominant IBS.
• Demonstrate dyssynergic pattern (Types I-IV; Figure) during attempted defecation on manometry recordings.
• Meet one or more of the following criteria:
• Inability to expel an artificial stool (50 mL water-filled balloon) within 1 minute.
• Inability to evacuate or retention of 50% or more of barium during defecography. (Some institutions use a prolonged colonic transit time: greater than 5 markers or 20% or higher marker retention on a plain abdominal x-Ray at 120 hours after ingestion of one radio-opaque marker capsule containing 24 radio-opaque markers.)

Treatment of DD

The treatment modalities for DD depend on several factors: patient’s age, comorbidities, underlying pathophysiology, and patient expectations. Treatment options include standard management of constipation, but biofeedback therapy is the mainstay.

Standard management

Medications that cause or worsen constipation should be avoided. The patient should consume adequate fluid and exercise regularly. Patients should receive instructions for timed toilet training (twice daily, 30 minutes after meals). Patients should push at about 50%-70% of their ability for no longer than 5 minutes and avoid postponing defecation or use of digital maneuvers to facilitate defecation.⁴² The patients should take 25 g of soluble fiber (e.g., psyllium) daily. Of note, the benefits of fiber can take days to weeks⁴⁴ and may be limited in patients with STC and DD.⁴⁵ Medications including laxatives and intestinal secretagogues (lubiprostone, linaclotide, plecanatide), and enterokinetic agents (prucalopride) can be used as adjunct therapy for management of DD.⁴² Their use is titrated during and after biofeedback therapy and may decrease after successful treatment.⁴⁶

Biofeedback therapy

Biofeedback therapy involves operant conditioning techniques using either a solid state anorectal manometry system, electromyography, simulated balloon, or home biofeedback training devices.^42,47 The goals of biofeedback therapy are to correct the abdominal pelvic muscle discoordination during defecation and improve rectal sensation to stool if impaired. Biofeedback therapy involves patient education and active training (typically six sessions, 1-2 weeks apart, with each about 30-60 minutes long), followed by a reinforcement stage (three sessions at 3, 6, and 12 months), though there are variations in training protocols.⁴²

The success of biofeedback therapy depends on the patient’s motivation and the therapist’s skills.⁴² Compared with standard therapy (diet, exercise, pharmacotherapy), biofeedback therapy provides sustained improvement of bowel symptoms and anorectal function. Up to 70%-80% of DD patients show significant improvement of symptoms in randomized controlled trials (Table).^48-52 Biofeedback therapy may also improve dyspeptic symptoms.⁵³ Patients with harder stool consistency, greater willingness to participate, lower baseline bowel satisfaction, lower baseline anal sphincter relaxation, and prolonged balloon expulsion time, as well as patients who used digital maneuvers for defection, more commonly respond to biofeedback therapy.^54,55 Longstanding laxative use has been associated with decreased response to biofeedback therapy.⁵⁶ In patients with rectal hyposensitivity, barostat-assisted sensory training is more effective than a hand-held syringe technique.³⁰ In patients with constipation predominant IBS and rectal hyposensitivity, sensory adaption training is more efficacious and better tolerated than escitalopram.³⁰ Biofeedback therapy was afforded a grade A recommendation for treatment of DD by the American and European Societies of Neurogastroenterology and Motility.⁵⁷

The access to office-based biofeedback therapy may be limited because of costs and low availability. The time required to attend multiple sessions may be burdensome for some patients, especially if they are taking time off from work. A recent study showed that patients with higher level of education may be less likely to adhere to biofeedback therapy.⁵⁸ Recently, home biofeedback was shown to be noninferior to office biofeedback and was more cost-effective, which provides an alternative option for treating more patients.⁵⁹

Endoscopic/surgical options

Other less effective treatment options for DD include botulinum toxin injection and myectomy.^60-62 Botulinum toxin injection appears to have mixed effects with less than 50% of patients reporting symptomatic improvement, and it may cause fecal incontinence.^60,63

 

Conclusion

DD is a common yet poorly recognized cause of constipation. Its clinical presentation overlaps with other lower-GI disorders. Its diagnosis requires detailed history, digital rectal examination, prospective stool diaries, anorectal manometry, and balloon expulsion tests. Biofeedback therapy offers excellent and sustained symptomatic improvement; however, access to office-based biofeedback is limited, and there is an urgent need for home-based biofeedback therapy programs.⁵⁹

Dr. Rao is J. Harold Harrison Distinguished University Chair, professor of medicine, director of neurogastroenterology/motility, and director of digestive health at the Digestive Health Clinical Research Center Augusta (Georgia) University. He is supported by National Institutes of Health grants R01DK121003-02 and U01DK115572. Dr. Jehangir is a gastroenterology and Hepatology Fellow at the Digestive Health Clinical Research Center at Augusta University. They reported having no conflicts of interest.

 

 

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3. Suares NC & Ford AC. Am J Gastroenterol. 2011 Sep;106(9):1582-91.

4. Mertz H, et al. Am J Gastroenterol. 1999;94(3):609-15.

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6. Rao SSC, et al. J Clin Gastroenterol. 2004;38(8):680-5.

7. Nojkov B, et al. Am J Gastroenterol. 2019;114(11):1772-7.

8. Heaton KW, et al. Gut. 1992;33(6):818-24.

9. Prichard DO & Bharucha AE. 2018 Oct 15;7:F1000 Faculty Rev-1640.

10. Ashraf W, et al. Am J Gastroenterol. 1996;91(1):26-32.

11. Agachan F, et al.. Dis Colon Rectum. 1996;39(6):681-5.

12. Frank L, et al. Scand J Gastroenterol. 1999;34(9):870-7.

13. Marquis P, et al. Scand J Gastroenterol. 2005;40(5):540-51.

14. Yan Y, et al. Gastroenterology. 2020;158(6):S-400.

15. Rao SSC. Am J Gastroenterol. 2018;113(5):635-8.

16. Tantiphlachiva K, et al. Digital rectal examination is a useful tool for identifying patients with dyssynergia. Clin Gastroenterol Hepatol. 2010;8(11):955-60.

17. Carrington EV, et al. Nat Rev Gastroenterol Hepatol. 2018;15(5):309-23.

18. Tetangco EP, et al. Performing and analyzing high-resolution anorectal manometry. NeuroGastroLatam Rev. 2018;2:120-32.

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20. Sharma M, et al. Neurogastroenterol Motil. 2020;32(10):e13910.

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22. Carrington EV, et al. Neurogastroenterol Motil. 2020;32(1):e13679.

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25. Guinet A, et al. Int J Colorectal Dis. 2011;26(4):507-13.

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27. Remes-Troche JM & Rao SSC. 2008;2(3):323-35.

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29. Remes-Troche JM, et al. Dis Colon Rectum. 2010;53(7):1047-54.

 

 

30. Rao SSC, et al. Gastroenterology. 2013;144(5):S-363.

31. Yu T, et al. Medicine (Baltimore). 2016;95(19):e3667.

32. Gladman MA, et al. Neurogastroenterol Motil. 2009;21(5):508-16, e4-5.

33. Lee KJ, et al. Digestion. 2006;73(2-3):133-41 .

34. Rao SSC, et al. Neurogastroenterol Motil. 2002;14(5):553-9.

35. Coss-Adame E, et al.. Clin Gastroenterol Hepatol. 2015;13(6):1143-1150.e1.

36. Chiarioni G, et al. Clin Gastroenterol Hepatol. 2014;12(12):2049-54.

37. Gu G, et al. Gastroenterology. 2018;154(6):S-545–S-546.

38. Savoye-Collet C, et al.. Gastroenterol Clin North Am. 2008;37(3):553-67, viii.

39. Videlock EJ, et al. Neurogastroenterol Motil. 2013;25(6):509-20.

40. Rao SSC, et al. Neurogastroenterol Motil. 2004;16(5):589-96.

41. Wald A, et al. Am J Gastroenterol. 2014;109(8):1141-57 ; (Quiz) 1058.

42. Rao SSC & Patcharatrakul T. J Neurogastroenterol Motil. 2016;22(3):423-35.

43. Rao SS, et al. Functional Anorectal Disorders. Gastroenterology. 2016. S0016-5085(16)00175-X.

44. Bharucha AE, et al.. Gastroenterology. 2013;144(1):218-38.

45. Voderholzer WA, et al. Am J Gastroenterol. 1997;92(1):95-8.

46. Lee HJ, et al. Neurogastroenterol Motil. 2015;27(6):787-95.

47. Simón MA & Bueno AM. J Clin Gastroenterol. 2017;51(10):e90-4.

48. Chiarioni G,et al.. Gastroenterology. 2006;130(3):657-64.

49. Heymen S, et al.. Dis Colon Rectum. 2007;50(4):428-41.

50. Rao SSC, et al. Clin Gastroenterol Hepatol. 2007;5(3):331-8.

51. Rao SSC, et al. Am J Gastroenterol. 2010;105(4):890-6.

52. Patcharatrakul T, et al. Biofeedback therapy. In Clinical and basic neurogastroenterology and motility. India: Stacy Masucci; 2020:517-32.

53. Huaman J-W, et al. Clin Gastroenterol Hepatol. 2020;18(11):2463-2470.e1.

54. Patcharatrakul T, et al. Clin Gastroenterol Hepatol. 2018;16(5):715-21.

55. Chaudhry A, et al. Gastroenterology. 2020;158(6):S-382–S-383.

56. Shim LSE, et al. Aliment Pharmacol Ther. 2011;33(11):1245-51.

57. Rao SSC, et al. Neurogastroenterol Motil. 2015;27(5):594-609.

58. Jangsirikul S, et al. Gastroenterology. 2020;158(6):S-383.

59. Rao SSC, et al. Am J Gastroenterol. 2019;114(6):938-44.

60. Ron Y, et al.. Dis Colon Rectum. 2001;44(12):1821-6.

61. Podzemny V, et al. World J Gastroenterol. 2015;21(4):1053-60.

62. Faried M, et al. J Gastrointest Surg. 2010;14(8):1235-43.

63. Hallan RI, et al. Lancet. 1988;2(8613):714-7.

Introduction

About 40% of the population experiences lower GI symptoms suggestive of gastrointestinal motility disorders.^1,2 The global prevalence of chronic constipation is 18%, and the condition includes multiple overlapping subtypes.³ Evacuation disorders affect over half (59%) of patients and include dyssynergic defecation (DD).⁴ The inability to coordinate the abdominal, rectal, pelvic floor, and anal/puborectalis muscles to evacuate stools causes DD.⁵ The etiology of DD remains unclear and is often misdiagnosed. Clinically, the symptoms of DD overlap with other lower GI disorders, often leading to unnecessary and invasive procedures.² We describe the clinical characteristics, diagnostic tools, treatment options, and evidence-based approach for the management of DD.

Vidyard Video

Clinical presentation

Over two-thirds of patients with DD acquire this disorder during adulthood, and one-third have symptoms from childhood.⁶ Though there is not usually an inciting event, 29% of patients report that symptoms began after events such as pregnancy or back injury,⁶ and opioid users have higher prevalence and severity of DD.⁷

Over 80% of patients report excessive straining, feelings of incomplete evacuation, and hard stools, and 50% report sensation of anal blockage or use of digital maneuvers.² Other symptoms include infrequent bowel movements, abdominal pain, anal pain, and stool leakage.² Evaluation of DD includes obtaining a detailed history utilizing the Bristol Stool Form Scale;⁸ however, patients’ recall of stool habit is often inaccurate, which results in suboptimal care.^9,10 Prospective stool diaries can help to provide more objective assessment of patients’ symptoms, eliminate recall bias, and provide more reliable information. Several useful questionnaires are available for clinical and research purposes to characterize lower-GI symptoms, including the Constipation Scoring System,¹¹ Patient Assessment of Constipation Symptoms (PAC-SYM),¹² and Patient Assessment of Constipation Quality of Life (PAC-QOL).^2,13 The Constipation Stool digital app enhances accuracy of data capture and offers a reliable and user-friendly method for recording bowel symptoms for patients, clinicians, and clinical investigators.¹⁴

 

Diagnosis

The diagnosis of DD requires careful physical and digital rectal examination together with anorectal manometry and a balloon expulsion test. Defecography and colonic transit studies provide additional assessment.

Physical examination

Abdominal examination should include palpation for stool in the colon and identification of abdominal mass or fecal impaction.²A high-quality digital rectal examination can help to identify patients who could benefit from physiological testing to confirm and treat DD.¹⁵ Rectal examination is performed by placing examiner’s lubricated gloved right index finger in a patient’s rectum, with the examiner’s left hand on patient’s abdomen, and asking the patient to push and bear down as if defecating.¹⁵ The contraction of the abdominal muscles is felt using the left hand, while the anal sphincter relaxation and degree of perineal descent are felt using the right-hand index finger.¹⁵ A diagnosis of dyssynergia is suspected if the digital rectal examination reveals two or more of the following abnormalities: inability to contract abdominal muscles (lack of push effort), inability to relax or paradoxical contraction of the anal sphincter and/or puborectalis, or absence of perineal descent.¹⁵ Digital rectal examination has good sensitivity (75%), specificity (87%), and positive predictive value (97%) for DD.¹⁶

 

 

High resolution anorectal manometry

Anorectal manometry (ARM) is the preferred method for the evaluation of defecatory disorders.^17,18 ARM is best performed using the high-resolution anorectal manometry (HRAM) systems¹⁹ that consist of a flexible probe – 0.5-cm diameter with multiple circumferential sensors along the anal canal – and another two sensors inside a rectal balloon.¹⁸ It provides a topographic and waveform display of manometric pressure data (Figure). The 3D high-definition ARM probe is a rigid 1-cm probe that provides 3D topographic profiles.¹⁸ ARM is typically performed in both the left lateral position and in a more physiological seated position.^20,21 There is considerable variation amongst different institutions on how to perform HRAM, and a recent International Anorectal Physiology Working Group (IAPWG) has provided consensus recommendations for performing this test.²² The procedure for performing HRAM is reviewed elsewhere, but the key elements are summarized below.¹⁸

Push maneuver: On HRAM, after the assessment of resting and squeeze anal sphincter pressures, the patient is asked to push or bear down as if to defecate while lying in left lateral decubitus position. The best of two attempts that closely mimics a normal bearing down maneuver is used for categorizing patient’s defecatory pattern.¹⁸ In patients with DD, at least four distinct dyssynergia phenotypes have been recognized (Figure),²³ though recent studies suggest eight patterns.²⁴ Defecation index (maximum rectal pressure/minimum residual anal pressure when bearing down) greater than 1.2 is considered normal.¹⁸

Simulated defecation on commode: The subject is asked to attempt defecation while seated on a commode with intrarectal balloon filled with 60 cc of air, and both the defecation pattern(s) and defecation index are calculated. A lack of coordinated push effort is highly suggestive of DD.²¹

Rectoanal Inhibitory Reflex (RAIR): RAIR describes the reflex relaxation of the internal anal sphincter after rectal distension. RAIR is dependent on intact autonomic ganglia and myenteric plexus²⁵and is mediated by the release of nitric oxide and vasoactive intestinal peptide.²⁶ The absence of RAIR suggests Hirschsprung disease.^22.27.28

Rectal sensory testing: Intermittent balloon distension of the rectum with incremental volumes of air induces a range of rectal sensations that include first sensation, desire to defecate, urgency to defecate, and maximum tolerable volume. Rectal hyposensitivity is diagnosed when two or more sensory thresholds are higher than those seen in normal subjects^29.30 and likely results from disruption of afferent gut-brain pathways, cortical perception/rectal wall dysfunction, or both.²⁹ Rectal hyposensitivity affects 40% of patients with constipation³⁰and is associated with DD but not delayed colonic transit.³¹ Rectal hyposensitivity may also be seen in patients with diabetes or fecal incontinence.¹⁸ About two-thirds of patients with rectal hyposensitivity have rectal hypercompliance, and some have megarectum.³² Some patients with DD have coexisting irritable bowel syndrome (IBS) and may have rectal hypersensitivity.^18,33 Rectal compliance is measured alongside rectal sensitivity analysis by plotting a graph between the change in intraballoon volume (mL) and change in intrarectal pressures (mm Hg) during incremental balloon distensions.^18.34 Rectal hypercompliance may be seen in megarectum and dyssynergic defecation.^34,35 Rectal hypocompliance may be seen in patients with inflammatory bowel disease, postpelvic radiation, chronic ischemia, and advanced age.¹⁸

Balloon expulsion test: This test is performed by placing a plastic probe with a balloon in the rectum and filling it with 50 cc of warm water. Patients are given 5 minutes to expel the balloon while sitting on a commode. Balloon expulsion time of more than 1 minute suggests a diagnosis of DD,²¹ although 2 minutes provides a higher level of agreement with manometric findings.³⁶ Balloon type and body position can influence the results.³⁷ Inability to expel the balloon with normal manometric findings is considered an inconclusive finding per the recent London Classification (i.e., it may be associated with generation of anorectal symptoms, but the clinical relevance of this finding is unclear as it may also be seen in healthy subjects).²²

 

 

Defecography

Defecography is a dynamic fluoroscopic study performed in the sitting position after injecting 150 mL of barium paste into the patient’s rectum. Defecography provides useful information about structural changes (e.g., rectoceles, enteroceles, rectal prolapse, and intussusception), DD, and descending perineum syndrome.³⁸ Methodological differences, radiation exposure, and poor interobserver agreement have limited its wider use; therefore, anorectal manometry and the balloon expulsion test are recommended for the initial evaluation of DD.³⁹ Magnetic resonance defecography may be more useful.^17,38

Colonic transit studies

Colonic transit study can be assessed using radiopaque markers, wireless motility capsule, or scintigraphy. Wireless motility capsule and scintigraphy have the advantage of determining gastric, small bowel, and whole gut transit times as well. About two-thirds of patients with DD have slow transit constipation (STC),⁶ which improves after treatment of DD.⁴⁰ Hence, in patients with chronic constipation, evaluation and management of DD is recommended first. If symptoms persist, then consider colonic transit assessment.⁴¹ Given the overlapping nature of the conditions, documentation of STC at the outset could facilitate treatment of both.

Diagnostic criteria for DD

Patients should fulfill the following criteria for diagnosis of DD:^42,43

• Fulfill symptom(s) diagnostic criteria for functional constipation and/or constipation-predominant IBS.
• Demonstrate dyssynergic pattern (Types I-IV; Figure) during attempted defecation on manometry recordings.
• Meet one or more of the following criteria:
• Inability to expel an artificial stool (50 mL water-filled balloon) within 1 minute.
• Inability to evacuate or retention of 50% or more of barium during defecography. (Some institutions use a prolonged colonic transit time: greater than 5 markers or 20% or higher marker retention on a plain abdominal x-Ray at 120 hours after ingestion of one radio-opaque marker capsule containing 24 radio-opaque markers.)

Treatment of DD

The treatment modalities for DD depend on several factors: patient’s age, comorbidities, underlying pathophysiology, and patient expectations. Treatment options include standard management of constipation, but biofeedback therapy is the mainstay.

Standard management

Medications that cause or worsen constipation should be avoided. The patient should consume adequate fluid and exercise regularly. Patients should receive instructions for timed toilet training (twice daily, 30 minutes after meals). Patients should push at about 50%-70% of their ability for no longer than 5 minutes and avoid postponing defecation or use of digital maneuvers to facilitate defecation.⁴² The patients should take 25 g of soluble fiber (e.g., psyllium) daily. Of note, the benefits of fiber can take days to weeks⁴⁴ and may be limited in patients with STC and DD.⁴⁵ Medications including laxatives and intestinal secretagogues (lubiprostone, linaclotide, plecanatide), and enterokinetic agents (prucalopride) can be used as adjunct therapy for management of DD.⁴² Their use is titrated during and after biofeedback therapy and may decrease after successful treatment.⁴⁶

Biofeedback therapy

Biofeedback therapy involves operant conditioning techniques using either a solid state anorectal manometry system, electromyography, simulated balloon, or home biofeedback training devices.^42,47 The goals of biofeedback therapy are to correct the abdominal pelvic muscle discoordination during defecation and improve rectal sensation to stool if impaired. Biofeedback therapy involves patient education and active training (typically six sessions, 1-2 weeks apart, with each about 30-60 minutes long), followed by a reinforcement stage (three sessions at 3, 6, and 12 months), though there are variations in training protocols.⁴²

The success of biofeedback therapy depends on the patient’s motivation and the therapist’s skills.⁴² Compared with standard therapy (diet, exercise, pharmacotherapy), biofeedback therapy provides sustained improvement of bowel symptoms and anorectal function. Up to 70%-80% of DD patients show significant improvement of symptoms in randomized controlled trials (Table).^48-52 Biofeedback therapy may also improve dyspeptic symptoms.⁵³ Patients with harder stool consistency, greater willingness to participate, lower baseline bowel satisfaction, lower baseline anal sphincter relaxation, and prolonged balloon expulsion time, as well as patients who used digital maneuvers for defection, more commonly respond to biofeedback therapy.^54,55 Longstanding laxative use has been associated with decreased response to biofeedback therapy.⁵⁶ In patients with rectal hyposensitivity, barostat-assisted sensory training is more effective than a hand-held syringe technique.³⁰ In patients with constipation predominant IBS and rectal hyposensitivity, sensory adaption training is more efficacious and better tolerated than escitalopram.³⁰ Biofeedback therapy was afforded a grade A recommendation for treatment of DD by the American and European Societies of Neurogastroenterology and Motility.⁵⁷

The access to office-based biofeedback therapy may be limited because of costs and low availability. The time required to attend multiple sessions may be burdensome for some patients, especially if they are taking time off from work. A recent study showed that patients with higher level of education may be less likely to adhere to biofeedback therapy.⁵⁸ Recently, home biofeedback was shown to be noninferior to office biofeedback and was more cost-effective, which provides an alternative option for treating more patients.⁵⁹

Endoscopic/surgical options

Other less effective treatment options for DD include botulinum toxin injection and myectomy.^60-62 Botulinum toxin injection appears to have mixed effects with less than 50% of patients reporting symptomatic improvement, and it may cause fecal incontinence.^60,63

 

Conclusion

DD is a common yet poorly recognized cause of constipation. Its clinical presentation overlaps with other lower-GI disorders. Its diagnosis requires detailed history, digital rectal examination, prospective stool diaries, anorectal manometry, and balloon expulsion tests. Biofeedback therapy offers excellent and sustained symptomatic improvement; however, access to office-based biofeedback is limited, and there is an urgent need for home-based biofeedback therapy programs.⁵⁹

Dr. Rao is J. Harold Harrison Distinguished University Chair, professor of medicine, director of neurogastroenterology/motility, and director of digestive health at the Digestive Health Clinical Research Center Augusta (Georgia) University. He is supported by National Institutes of Health grants R01DK121003-02 and U01DK115572. Dr. Jehangir is a gastroenterology and Hepatology Fellow at the Digestive Health Clinical Research Center at Augusta University. They reported having no conflicts of interest.

 

 

References

1. Peery AF, et al. Gastroenterology. 2012;143(5):1179-1187.e3 .

2. Curtin B, et al. J Neurogastroenterol Motil. 2020 30;26(4):423-36.

3. Suares NC & Ford AC. Am J Gastroenterol. 2011 Sep;106(9):1582-91.

4. Mertz H, et al. Am J Gastroenterol. 1999;94(3):609-15.

5. Rao SS, et al. Am J Gastroenterol. 1998;93(7):1042-50.

6. Rao SSC, et al. J Clin Gastroenterol. 2004;38(8):680-5.

7. Nojkov B, et al. Am J Gastroenterol. 2019;114(11):1772-7.

8. Heaton KW, et al. Gut. 1992;33(6):818-24.

9. Prichard DO & Bharucha AE. 2018 Oct 15;7:F1000 Faculty Rev-1640.

10. Ashraf W, et al. Am J Gastroenterol. 1996;91(1):26-32.

11. Agachan F, et al.. Dis Colon Rectum. 1996;39(6):681-5.

12. Frank L, et al. Scand J Gastroenterol. 1999;34(9):870-7.

13. Marquis P, et al. Scand J Gastroenterol. 2005;40(5):540-51.

14. Yan Y, et al. Gastroenterology. 2020;158(6):S-400.

15. Rao SSC. Am J Gastroenterol. 2018;113(5):635-8.

16. Tantiphlachiva K, et al. Digital rectal examination is a useful tool for identifying patients with dyssynergia. Clin Gastroenterol Hepatol. 2010;8(11):955-60.

17. Carrington EV, et al. Nat Rev Gastroenterol Hepatol. 2018;15(5):309-23.

18. Tetangco EP, et al. Performing and analyzing high-resolution anorectal manometry. NeuroGastroLatam Rev. 2018;2:120-32.

19. Lee YY, et al. Curr Gastroenterol Rep. 2013;15(12):360.

20. Sharma M, et al. Neurogastroenterol Motil. 2020;32(10):e13910.

21. Rao SSC, et al.. Am J Gastroenterol. 2006;101(12):2790-6.

22. Carrington EV, et al. Neurogastroenterol Motil. 2020;32(1):e13679.

23. Rao SSC. Gastroenterol Clin North Am. 2008;37(3):569-86, viii.

24. Rao SSC, et al. Gastroenterology. 2016;150(4):S158-9.

25. Guinet A, et al. Int J Colorectal Dis. 2011;26(4):507-13.

26. Rattan S, et al. Gastroenterology. 1992;103(1):43-50.

27. Remes-Troche JM & Rao SSC. 2008;2(3):323-35.

28. Zaafouri H, et al..Int J Surgery. 2015. 2(1):9-17.

29. Remes-Troche JM, et al. Dis Colon Rectum. 2010;53(7):1047-54.

 

 

30. Rao SSC, et al. Gastroenterology. 2013;144(5):S-363.

31. Yu T, et al. Medicine (Baltimore). 2016;95(19):e3667.

32. Gladman MA, et al. Neurogastroenterol Motil. 2009;21(5):508-16, e4-5.

33. Lee KJ, et al. Digestion. 2006;73(2-3):133-41 .

34. Rao SSC, et al. Neurogastroenterol Motil. 2002;14(5):553-9.

35. Coss-Adame E, et al.. Clin Gastroenterol Hepatol. 2015;13(6):1143-1150.e1.

36. Chiarioni G, et al. Clin Gastroenterol Hepatol. 2014;12(12):2049-54.

37. Gu G, et al. Gastroenterology. 2018;154(6):S-545–S-546.

38. Savoye-Collet C, et al.. Gastroenterol Clin North Am. 2008;37(3):553-67, viii.

39. Videlock EJ, et al. Neurogastroenterol Motil. 2013;25(6):509-20.

40. Rao SSC, et al. Neurogastroenterol Motil. 2004;16(5):589-96.

41. Wald A, et al. Am J Gastroenterol. 2014;109(8):1141-57 ; (Quiz) 1058.

42. Rao SSC & Patcharatrakul T. J Neurogastroenterol Motil. 2016;22(3):423-35.

43. Rao SS, et al. Functional Anorectal Disorders. Gastroenterology. 2016. S0016-5085(16)00175-X.

44. Bharucha AE, et al.. Gastroenterology. 2013;144(1):218-38.

45. Voderholzer WA, et al. Am J Gastroenterol. 1997;92(1):95-8.

46. Lee HJ, et al. Neurogastroenterol Motil. 2015;27(6):787-95.

47. Simón MA & Bueno AM. J Clin Gastroenterol. 2017;51(10):e90-4.

48. Chiarioni G,et al.. Gastroenterology. 2006;130(3):657-64.

49. Heymen S, et al.. Dis Colon Rectum. 2007;50(4):428-41.

50. Rao SSC, et al. Clin Gastroenterol Hepatol. 2007;5(3):331-8.

51. Rao SSC, et al. Am J Gastroenterol. 2010;105(4):890-6.

52. Patcharatrakul T, et al. Biofeedback therapy. In Clinical and basic neurogastroenterology and motility. India: Stacy Masucci; 2020:517-32.

53. Huaman J-W, et al. Clin Gastroenterol Hepatol. 2020;18(11):2463-2470.e1.

54. Patcharatrakul T, et al. Clin Gastroenterol Hepatol. 2018;16(5):715-21.

55. Chaudhry A, et al. Gastroenterology. 2020;158(6):S-382–S-383.

56. Shim LSE, et al. Aliment Pharmacol Ther. 2011;33(11):1245-51.

57. Rao SSC, et al. Neurogastroenterol Motil. 2015;27(5):594-609.

58. Jangsirikul S, et al. Gastroenterology. 2020;158(6):S-383.

59. Rao SSC, et al. Am J Gastroenterol. 2019;114(6):938-44.

60. Ron Y, et al.. Dis Colon Rectum. 2001;44(12):1821-6.

61. Podzemny V, et al. World J Gastroenterol. 2015;21(4):1053-60.

62. Faried M, et al. J Gastrointest Surg. 2010;14(8):1235-43.

63. Hallan RI, et al. Lancet. 1988;2(8613):714-7.

Introduction

About 40% of the population experiences lower GI symptoms suggestive of gastrointestinal motility disorders.^1,2 The global prevalence of chronic constipation is 18%, and the condition includes multiple overlapping subtypes.³ Evacuation disorders affect over half (59%) of patients and include dyssynergic defecation (DD).⁴ The inability to coordinate the abdominal, rectal, pelvic floor, and anal/puborectalis muscles to evacuate stools causes DD.⁵ The etiology of DD remains unclear and is often misdiagnosed. Clinically, the symptoms of DD overlap with other lower GI disorders, often leading to unnecessary and invasive procedures.² We describe the clinical characteristics, diagnostic tools, treatment options, and evidence-based approach for the management of DD.

Vidyard Video

Clinical presentation

Over two-thirds of patients with DD acquire this disorder during adulthood, and one-third have symptoms from childhood.⁶ Though there is not usually an inciting event, 29% of patients report that symptoms began after events such as pregnancy or back injury,⁶ and opioid users have higher prevalence and severity of DD.⁷

Over 80% of patients report excessive straining, feelings of incomplete evacuation, and hard stools, and 50% report sensation of anal blockage or use of digital maneuvers.² Other symptoms include infrequent bowel movements, abdominal pain, anal pain, and stool leakage.² Evaluation of DD includes obtaining a detailed history utilizing the Bristol Stool Form Scale;⁸ however, patients’ recall of stool habit is often inaccurate, which results in suboptimal care.^9,10 Prospective stool diaries can help to provide more objective assessment of patients’ symptoms, eliminate recall bias, and provide more reliable information. Several useful questionnaires are available for clinical and research purposes to characterize lower-GI symptoms, including the Constipation Scoring System,¹¹ Patient Assessment of Constipation Symptoms (PAC-SYM),¹² and Patient Assessment of Constipation Quality of Life (PAC-QOL).^2,13 The Constipation Stool digital app enhances accuracy of data capture and offers a reliable and user-friendly method for recording bowel symptoms for patients, clinicians, and clinical investigators.¹⁴

 

Diagnosis

The diagnosis of DD requires careful physical and digital rectal examination together with anorectal manometry and a balloon expulsion test. Defecography and colonic transit studies provide additional assessment.

Physical examination

Abdominal examination should include palpation for stool in the colon and identification of abdominal mass or fecal impaction.²A high-quality digital rectal examination can help to identify patients who could benefit from physiological testing to confirm and treat DD.¹⁵ Rectal examination is performed by placing examiner’s lubricated gloved right index finger in a patient’s rectum, with the examiner’s left hand on patient’s abdomen, and asking the patient to push and bear down as if defecating.¹⁵ The contraction of the abdominal muscles is felt using the left hand, while the anal sphincter relaxation and degree of perineal descent are felt using the right-hand index finger.¹⁵ A diagnosis of dyssynergia is suspected if the digital rectal examination reveals two or more of the following abnormalities: inability to contract abdominal muscles (lack of push effort), inability to relax or paradoxical contraction of the anal sphincter and/or puborectalis, or absence of perineal descent.¹⁵ Digital rectal examination has good sensitivity (75%), specificity (87%), and positive predictive value (97%) for DD.¹⁶

 

 

High resolution anorectal manometry

Anorectal manometry (ARM) is the preferred method for the evaluation of defecatory disorders.^17,18 ARM is best performed using the high-resolution anorectal manometry (HRAM) systems¹⁹ that consist of a flexible probe – 0.5-cm diameter with multiple circumferential sensors along the anal canal – and another two sensors inside a rectal balloon.¹⁸ It provides a topographic and waveform display of manometric pressure data (Figure). The 3D high-definition ARM probe is a rigid 1-cm probe that provides 3D topographic profiles.¹⁸ ARM is typically performed in both the left lateral position and in a more physiological seated position.^20,21 There is considerable variation amongst different institutions on how to perform HRAM, and a recent International Anorectal Physiology Working Group (IAPWG) has provided consensus recommendations for performing this test.²² The procedure for performing HRAM is reviewed elsewhere, but the key elements are summarized below.¹⁸

Push maneuver: On HRAM, after the assessment of resting and squeeze anal sphincter pressures, the patient is asked to push or bear down as if to defecate while lying in left lateral decubitus position. The best of two attempts that closely mimics a normal bearing down maneuver is used for categorizing patient’s defecatory pattern.¹⁸ In patients with DD, at least four distinct dyssynergia phenotypes have been recognized (Figure),²³ though recent studies suggest eight patterns.²⁴ Defecation index (maximum rectal pressure/minimum residual anal pressure when bearing down) greater than 1.2 is considered normal.¹⁸

Simulated defecation on commode: The subject is asked to attempt defecation while seated on a commode with intrarectal balloon filled with 60 cc of air, and both the defecation pattern(s) and defecation index are calculated. A lack of coordinated push effort is highly suggestive of DD.²¹

Rectoanal Inhibitory Reflex (RAIR): RAIR describes the reflex relaxation of the internal anal sphincter after rectal distension. RAIR is dependent on intact autonomic ganglia and myenteric plexus²⁵and is mediated by the release of nitric oxide and vasoactive intestinal peptide.²⁶ The absence of RAIR suggests Hirschsprung disease.^22.27.28

Rectal sensory testing: Intermittent balloon distension of the rectum with incremental volumes of air induces a range of rectal sensations that include first sensation, desire to defecate, urgency to defecate, and maximum tolerable volume. Rectal hyposensitivity is diagnosed when two or more sensory thresholds are higher than those seen in normal subjects^29.30 and likely results from disruption of afferent gut-brain pathways, cortical perception/rectal wall dysfunction, or both.²⁹ Rectal hyposensitivity affects 40% of patients with constipation³⁰and is associated with DD but not delayed colonic transit.³¹ Rectal hyposensitivity may also be seen in patients with diabetes or fecal incontinence.¹⁸ About two-thirds of patients with rectal hyposensitivity have rectal hypercompliance, and some have megarectum.³² Some patients with DD have coexisting irritable bowel syndrome (IBS) and may have rectal hypersensitivity.^18,33 Rectal compliance is measured alongside rectal sensitivity analysis by plotting a graph between the change in intraballoon volume (mL) and change in intrarectal pressures (mm Hg) during incremental balloon distensions.^18.34 Rectal hypercompliance may be seen in megarectum and dyssynergic defecation.^34,35 Rectal hypocompliance may be seen in patients with inflammatory bowel disease, postpelvic radiation, chronic ischemia, and advanced age.¹⁸

Balloon expulsion test: This test is performed by placing a plastic probe with a balloon in the rectum and filling it with 50 cc of warm water. Patients are given 5 minutes to expel the balloon while sitting on a commode. Balloon expulsion time of more than 1 minute suggests a diagnosis of DD,²¹ although 2 minutes provides a higher level of agreement with manometric findings.³⁶ Balloon type and body position can influence the results.³⁷ Inability to expel the balloon with normal manometric findings is considered an inconclusive finding per the recent London Classification (i.e., it may be associated with generation of anorectal symptoms, but the clinical relevance of this finding is unclear as it may also be seen in healthy subjects).²²

 

 

Defecography

Defecography is a dynamic fluoroscopic study performed in the sitting position after injecting 150 mL of barium paste into the patient’s rectum. Defecography provides useful information about structural changes (e.g., rectoceles, enteroceles, rectal prolapse, and intussusception), DD, and descending perineum syndrome.³⁸ Methodological differences, radiation exposure, and poor interobserver agreement have limited its wider use; therefore, anorectal manometry and the balloon expulsion test are recommended for the initial evaluation of DD.³⁹ Magnetic resonance defecography may be more useful.^17,38

Colonic transit studies

Colonic transit study can be assessed using radiopaque markers, wireless motility capsule, or scintigraphy. Wireless motility capsule and scintigraphy have the advantage of determining gastric, small bowel, and whole gut transit times as well. About two-thirds of patients with DD have slow transit constipation (STC),⁶ which improves after treatment of DD.⁴⁰ Hence, in patients with chronic constipation, evaluation and management of DD is recommended first. If symptoms persist, then consider colonic transit assessment.⁴¹ Given the overlapping nature of the conditions, documentation of STC at the outset could facilitate treatment of both.

Diagnostic criteria for DD

Patients should fulfill the following criteria for diagnosis of DD:^42,43

• Fulfill symptom(s) diagnostic criteria for functional constipation and/or constipation-predominant IBS.
• Demonstrate dyssynergic pattern (Types I-IV; Figure) during attempted defecation on manometry recordings.
• Meet one or more of the following criteria:
• Inability to expel an artificial stool (50 mL water-filled balloon) within 1 minute.
• Inability to evacuate or retention of 50% or more of barium during defecography. (Some institutions use a prolonged colonic transit time: greater than 5 markers or 20% or higher marker retention on a plain abdominal x-Ray at 120 hours after ingestion of one radio-opaque marker capsule containing 24 radio-opaque markers.)

Treatment of DD

The treatment modalities for DD depend on several factors: patient’s age, comorbidities, underlying pathophysiology, and patient expectations. Treatment options include standard management of constipation, but biofeedback therapy is the mainstay.

Standard management

Medications that cause or worsen constipation should be avoided. The patient should consume adequate fluid and exercise regularly. Patients should receive instructions for timed toilet training (twice daily, 30 minutes after meals). Patients should push at about 50%-70% of their ability for no longer than 5 minutes and avoid postponing defecation or use of digital maneuvers to facilitate defecation.⁴² The patients should take 25 g of soluble fiber (e.g., psyllium) daily. Of note, the benefits of fiber can take days to weeks⁴⁴ and may be limited in patients with STC and DD.⁴⁵ Medications including laxatives and intestinal secretagogues (lubiprostone, linaclotide, plecanatide), and enterokinetic agents (prucalopride) can be used as adjunct therapy for management of DD.⁴² Their use is titrated during and after biofeedback therapy and may decrease after successful treatment.⁴⁶

Biofeedback therapy

Biofeedback therapy involves operant conditioning techniques using either a solid state anorectal manometry system, electromyography, simulated balloon, or home biofeedback training devices.^42,47 The goals of biofeedback therapy are to correct the abdominal pelvic muscle discoordination during defecation and improve rectal sensation to stool if impaired. Biofeedback therapy involves patient education and active training (typically six sessions, 1-2 weeks apart, with each about 30-60 minutes long), followed by a reinforcement stage (three sessions at 3, 6, and 12 months), though there are variations in training protocols.⁴²

The success of biofeedback therapy depends on the patient’s motivation and the therapist’s skills.⁴² Compared with standard therapy (diet, exercise, pharmacotherapy), biofeedback therapy provides sustained improvement of bowel symptoms and anorectal function. Up to 70%-80% of DD patients show significant improvement of symptoms in randomized controlled trials (Table).^48-52 Biofeedback therapy may also improve dyspeptic symptoms.⁵³ Patients with harder stool consistency, greater willingness to participate, lower baseline bowel satisfaction, lower baseline anal sphincter relaxation, and prolonged balloon expulsion time, as well as patients who used digital maneuvers for defection, more commonly respond to biofeedback therapy.^54,55 Longstanding laxative use has been associated with decreased response to biofeedback therapy.⁵⁶ In patients with rectal hyposensitivity, barostat-assisted sensory training is more effective than a hand-held syringe technique.³⁰ In patients with constipation predominant IBS and rectal hyposensitivity, sensory adaption training is more efficacious and better tolerated than escitalopram.³⁰ Biofeedback therapy was afforded a grade A recommendation for treatment of DD by the American and European Societies of Neurogastroenterology and Motility.⁵⁷

The access to office-based biofeedback therapy may be limited because of costs and low availability. The time required to attend multiple sessions may be burdensome for some patients, especially if they are taking time off from work. A recent study showed that patients with higher level of education may be less likely to adhere to biofeedback therapy.⁵⁸ Recently, home biofeedback was shown to be noninferior to office biofeedback and was more cost-effective, which provides an alternative option for treating more patients.⁵⁹

Endoscopic/surgical options

Other less effective treatment options for DD include botulinum toxin injection and myectomy.^60-62 Botulinum toxin injection appears to have mixed effects with less than 50% of patients reporting symptomatic improvement, and it may cause fecal incontinence.^60,63

 

Conclusion

DD is a common yet poorly recognized cause of constipation. Its clinical presentation overlaps with other lower-GI disorders. Its diagnosis requires detailed history, digital rectal examination, prospective stool diaries, anorectal manometry, and balloon expulsion tests. Biofeedback therapy offers excellent and sustained symptomatic improvement; however, access to office-based biofeedback is limited, and there is an urgent need for home-based biofeedback therapy programs.⁵⁹

Dr. Rao is J. Harold Harrison Distinguished University Chair, professor of medicine, director of neurogastroenterology/motility, and director of digestive health at the Digestive Health Clinical Research Center Augusta (Georgia) University. He is supported by National Institutes of Health grants R01DK121003-02 and U01DK115572. Dr. Jehangir is a gastroenterology and Hepatology Fellow at the Digestive Health Clinical Research Center at Augusta University. They reported having no conflicts of interest.

 

 

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AGAF applications now open

Applications are now open for the 2022 American Gastroenterological Association Fellowship cohort. AGA is proud to formally recognize its exemplary members whose accomplishments and contributions demonstrate a deep commitment to gastroenterology through the AGA Fellows Program. Those in clinical practice, education, or research (basic or clinical) are encouraged to apply today.

Longstanding members who apply and meet the program criteria are granted the distinguished honor of AGA Fellowship and receive the following:

• The privilege of using the designation “AGAF” in professional activities. 
• An official certificate and pin denoting your status. 
• International acknowledgment at Digestive Disease Week® (DDW).
• A listing on the AGA website alongside esteemed peers.  
• A prewritten, fill-in press release and a digital badge to inform others of your accomplishment.

Apply for consideration and gain recognition worldwide for your commitment to the field. The deadline is Aug. 24.
 

Call for new AGA guideline topics

The AGA Institute Clinical Guidelines Committee wants your input on the next set of guidelines to be developed. By completing this online form, you can submit recommendations for guideline topics that will be developed within the next two years. The deadline to submit your ideas is Monday, May 3.  

It’s easy – just take the following 3 steps to submit a guideline idea:

• Check out the guidelines that AGA has already developed or are in progress. 
• Complete the survey. You can submit more than one guideline topic by filling out the form multiple times. 
• Stay tuned for follow-up questions in case the committee needs more information on your recommendations.  

The AGA Institute Clinical Guidelines Committee will review guideline topics in May, prioritizing and ranking topics based on the following criteria: prevalence of disease, resource utilization, variation in care, other existing guidelines, new data/changes in diagnosis or treatment, and potential for measure/quality development. Once vetted, four or more new guidelines will be recommended for development throughout the year. Complete the online survey at www.surveymonkey.com/r/AGAtopicsubmission
 

Get to know DDW® 2021 Virtual

The world’s premier meeting for gastroenterology, hepatology, endoscopy, and gastrointestinal surgery professionals will be a fully virtual event, May 21-23, 2021. We invite you to take advantage of this unique opportunity to exchange knowledge with colleagues from all over the world and explore the latest advances in the field – all from the convenience of your home. Plus, your registration grants you access to everything offered at Digestive Disease Week® (DDW) this year (no additional ticketed sessions). Learn more and register at ddw.org.

AGAF applications now open

Applications are now open for the 2022 American Gastroenterological Association Fellowship cohort. AGA is proud to formally recognize its exemplary members whose accomplishments and contributions demonstrate a deep commitment to gastroenterology through the AGA Fellows Program. Those in clinical practice, education, or research (basic or clinical) are encouraged to apply today.

Longstanding members who apply and meet the program criteria are granted the distinguished honor of AGA Fellowship and receive the following:

• The privilege of using the designation “AGAF” in professional activities. 
• An official certificate and pin denoting your status. 
• International acknowledgment at Digestive Disease Week® (DDW).
• A listing on the AGA website alongside esteemed peers.  
• A prewritten, fill-in press release and a digital badge to inform others of your accomplishment.

Apply for consideration and gain recognition worldwide for your commitment to the field. The deadline is Aug. 24.
 

Call for new AGA guideline topics

The AGA Institute Clinical Guidelines Committee wants your input on the next set of guidelines to be developed. By completing this online form, you can submit recommendations for guideline topics that will be developed within the next two years. The deadline to submit your ideas is Monday, May 3.  

It’s easy – just take the following 3 steps to submit a guideline idea:

• Check out the guidelines that AGA has already developed or are in progress. 
• Complete the survey. You can submit more than one guideline topic by filling out the form multiple times. 
• Stay tuned for follow-up questions in case the committee needs more information on your recommendations.  

The AGA Institute Clinical Guidelines Committee will review guideline topics in May, prioritizing and ranking topics based on the following criteria: prevalence of disease, resource utilization, variation in care, other existing guidelines, new data/changes in diagnosis or treatment, and potential for measure/quality development. Once vetted, four or more new guidelines will be recommended for development throughout the year. Complete the online survey at www.surveymonkey.com/r/AGAtopicsubmission
 

Get to know DDW® 2021 Virtual

The world’s premier meeting for gastroenterology, hepatology, endoscopy, and gastrointestinal surgery professionals will be a fully virtual event, May 21-23, 2021. We invite you to take advantage of this unique opportunity to exchange knowledge with colleagues from all over the world and explore the latest advances in the field – all from the convenience of your home. Plus, your registration grants you access to everything offered at Digestive Disease Week® (DDW) this year (no additional ticketed sessions). Learn more and register at ddw.org.

AGAF applications now open

Applications are now open for the 2022 American Gastroenterological Association Fellowship cohort. AGA is proud to formally recognize its exemplary members whose accomplishments and contributions demonstrate a deep commitment to gastroenterology through the AGA Fellows Program. Those in clinical practice, education, or research (basic or clinical) are encouraged to apply today.

Longstanding members who apply and meet the program criteria are granted the distinguished honor of AGA Fellowship and receive the following:

• The privilege of using the designation “AGAF” in professional activities. 
• An official certificate and pin denoting your status. 
• International acknowledgment at Digestive Disease Week® (DDW).
• A listing on the AGA website alongside esteemed peers.  
• A prewritten, fill-in press release and a digital badge to inform others of your accomplishment.

Apply for consideration and gain recognition worldwide for your commitment to the field. The deadline is Aug. 24.
 

Call for new AGA guideline topics

The AGA Institute Clinical Guidelines Committee wants your input on the next set of guidelines to be developed. By completing this online form, you can submit recommendations for guideline topics that will be developed within the next two years. The deadline to submit your ideas is Monday, May 3.  

It’s easy – just take the following 3 steps to submit a guideline idea:

• Check out the guidelines that AGA has already developed or are in progress. 
• Complete the survey. You can submit more than one guideline topic by filling out the form multiple times. 
• Stay tuned for follow-up questions in case the committee needs more information on your recommendations.  

The AGA Institute Clinical Guidelines Committee will review guideline topics in May, prioritizing and ranking topics based on the following criteria: prevalence of disease, resource utilization, variation in care, other existing guidelines, new data/changes in diagnosis or treatment, and potential for measure/quality development. Once vetted, four or more new guidelines will be recommended for development throughout the year. Complete the online survey at www.surveymonkey.com/r/AGAtopicsubmission
 

Get to know DDW® 2021 Virtual

The world’s premier meeting for gastroenterology, hepatology, endoscopy, and gastrointestinal surgery professionals will be a fully virtual event, May 21-23, 2021. We invite you to take advantage of this unique opportunity to exchange knowledge with colleagues from all over the world and explore the latest advances in the field – all from the convenience of your home. Plus, your registration grants you access to everything offered at Digestive Disease Week® (DDW) this year (no additional ticketed sessions). Learn more and register at ddw.org.

Gastroenterology

February 2021

Worldwide burden of, risk factors for, and trends in pancreatic cancer
Huang J et al. Gastroenterology. 2021 Mar 1;160(4):744-54. doi: 10.1053/j.gastro.2020.10.007.

Fibrates for Itch (FITCH) in fibrosing cholangiopathies: A double-blind, randomized, placebo-controlled trial
de Vries E et al. Gastroenterology. 2021 Mar 1;160(4):734-43.e6. doi: 10.1053/j.gastro.2020.10.001.



March 2021

How to integrate a medical ethics curriculum into gastroenterology fellowships
Rao VL et al. Gastroenterology. 2021 Mar 1;160(4):1003-6. https://doi.org/10.1053/j.gastro.2021.01.211.

Colonoscopist performance and colorectal cancer risk after adenoma removal to stratify surveillance: two nationwide observational studies
Wieszczy P et al. Gastroenterology. 2021 Mar 1;160(4):1067-74. doi: 10.1053/j.gastro.2020.10.009.

Pregnancy and neonatal outcomes after fetal exposure to biologics and thiopurines among women with inflammatory bowel disease
Mahadevan U et al. Gastroenterology. 2021 Mar 1;160(4):1131-9. doi: 10.1053/j.gastro.2020.11.038.


April 2021

AGA Clinical Practice Guidelines on intragastric balloons in the management of obesity
Muniraj T et al. Gastroenterology. 2021 Apr 1;160(5):1799-808. doi: 10.1053/j.gastro.2021.03.003.

How to strategically build your network for early career gastroenterologists
Gaidos JKJ et al. Gastroenterology. 2021 Apr 1;160(5):1461-6. doi: 10.1053/j.gastro.2021.01.025.

The microbiota-gut-brain axis: From motility to mood
Margolis KG et al. Gastroenterology. 2021 Apr 1;160(5):1486-501. doi: 10.1053/j.gastro.2020.10.066.

The association of histologic and noninvasive tests with adverse clinical and patient-reported outcomes in patients with advanced fibrosis due to nonalcoholic steatohepatitis
Younossi ZM et al. Gastroenterology. 2021 Apr 1;160(5):1608-19. doi: 10.1053/j.gastro.2020.12.003.
 

Clinical Gastroenterology and Hepatology

February 2021

Management of chronic abdominal distension and bloating
Lacy BE et al. Clin Gastroenterol Hepatol. 2021 Feb 1;19(2):219-31. doi: 10.1016/j.cgh.2020.03.056.

Prevalence of gastric intestinal metaplasia in a multiethnic US veterans population
Nguyen TH et al. Clin Gastroenterol Hepatol. 2021 Feb 1;19(2):269-76. doi: 10.1016/j.cgh.2020.03.015.

Rome IV functional gastrointestinal disorders and health impairment in subjects with hypermobility spectrum disorders or hypermobile Ehlers-Danlos syndrome
Lam CY et al. Clin Gastroenterol Hepatol. 2021 Feb 1;19(2):277-87. doi: 10.1016/j.cgh.2020.02.034.

Factors that affect adequacy of colon cleansing for colonoscopy in hospitalized patients
Fucci L et al. Clin Gastroenterol Hepatol. 2021 Feb 1;19(2):339-48. doi: org/10.1016/j.cgh.2020.02.055.


March 2021

Real-world gluten exposure in patients with celiac disease on gluten-free diets, determined from gliadin immunogenic peptides in urine and fecal samples
Stefanolo JP et al. Clin Gastroenterol Hepatol. 2021 Mar 1;19(3):484-91. doi: 10.1016/j.cgh.2020.03.038.



Factors associated with response to anorectal biofeedback therapy in patients with fecal incontinence

Mazor Y et al. Clin Gastroenterol Hepatol. 2021 Mar 1;19(3):492-502. doi: 10.1016/j.cgh.2020.03.050.



April 2021

Long-term outcome of gastric per-oral endoscopic pyloromyotomy in treatment of gastroparesis

Abdelfatah MM et al. Clin Gastroenterol Hepatol. 2021 Apr 1;19(4):816-24. doi: 10.1016/j.cgh.2020.05.039.



What gastroenterologists should know about COVID-19 vaccines

Rolak S et al. Clin Gastroenterol Hepatol. 2021 Apr 1;19(4):657-61. doi: 10.1016/j.cgh.2021.01.001.



No benefit of concomitant immunomodulator therapy on efficacy of biologics that are not tumor necrosis factor antagonists in patients with inflammatory bowel diseases: A meta-analysis

Yzet C et al. Clin Gastroenterol Hepatol. 2021 Apr 1;19(4):668-78. doi: 10.1016/j.cgh.2020.06.071.



Patient safety reporting in GI: All hands on deck

Wall A and Kothari D. Clin Gastroenterol Hepatol. 2021 Apr 1;19(4):626-32. doi: 10.1016/j.cgh.2020.11.007.

Techniques and Innovations in Gastrointestinal Endoscopy

Barriers and pitfalls for artificial intelligence in gastroenterology: Ethical and regulatory issues

Ahmad OF et al. Tech Innov Gastrointest Endosc. 2020 Apr 1;22(2):80-4. doi: 10.1016/j.tgie.2019.150636.



Development of a scoring system to predict a positive diagnosis on video capsule endoscopy for suspected small bowel bleeding

Marya NB et al. Tech Innov Gastrointest Endosc. 2020 Oct 1;22(4):178-84. doi: 10.1016/j.tige.2020.06.001.



Training for Advanced Endoscopic Imaging in Gastrointestinal Diseases

Hoogenboom SA et al. Tech Innov Gastrointest Endosc. 2021 Jan 1;23(1):99-106. doi: 10.1016/j.tige.2020.09.001.



Chromoendoscopy techniques in imaging of colorectal polyps and cancer: Overview and practical applications for detection and characterization.

Rivero-Sanchez L et al. Tech Innov Gastrointest Endosc. 2021 Jan 1;23(1):30-41. doi: 10.1016/j.tige.2020.10.006.




 

Gastroenterology

February 2021

Worldwide burden of, risk factors for, and trends in pancreatic cancer
Huang J et al. Gastroenterology. 2021 Mar 1;160(4):744-54. doi: 10.1053/j.gastro.2020.10.007.

Fibrates for Itch (FITCH) in fibrosing cholangiopathies: A double-blind, randomized, placebo-controlled trial
de Vries E et al. Gastroenterology. 2021 Mar 1;160(4):734-43.e6. doi: 10.1053/j.gastro.2020.10.001.



March 2021

How to integrate a medical ethics curriculum into gastroenterology fellowships
Rao VL et al. Gastroenterology. 2021 Mar 1;160(4):1003-6. https://doi.org/10.1053/j.gastro.2021.01.211.

Colonoscopist performance and colorectal cancer risk after adenoma removal to stratify surveillance: two nationwide observational studies
Wieszczy P et al. Gastroenterology. 2021 Mar 1;160(4):1067-74. doi: 10.1053/j.gastro.2020.10.009.

Pregnancy and neonatal outcomes after fetal exposure to biologics and thiopurines among women with inflammatory bowel disease
Mahadevan U et al. Gastroenterology. 2021 Mar 1;160(4):1131-9. doi: 10.1053/j.gastro.2020.11.038.


April 2021

AGA Clinical Practice Guidelines on intragastric balloons in the management of obesity
Muniraj T et al. Gastroenterology. 2021 Apr 1;160(5):1799-808. doi: 10.1053/j.gastro.2021.03.003.

How to strategically build your network for early career gastroenterologists
Gaidos JKJ et al. Gastroenterology. 2021 Apr 1;160(5):1461-6. doi: 10.1053/j.gastro.2021.01.025.

The microbiota-gut-brain axis: From motility to mood
Margolis KG et al. Gastroenterology. 2021 Apr 1;160(5):1486-501. doi: 10.1053/j.gastro.2020.10.066.

The association of histologic and noninvasive tests with adverse clinical and patient-reported outcomes in patients with advanced fibrosis due to nonalcoholic steatohepatitis
Younossi ZM et al. Gastroenterology. 2021 Apr 1;160(5):1608-19. doi: 10.1053/j.gastro.2020.12.003.
 

Clinical Gastroenterology and Hepatology

February 2021

Management of chronic abdominal distension and bloating
Lacy BE et al. Clin Gastroenterol Hepatol. 2021 Feb 1;19(2):219-31. doi: 10.1016/j.cgh.2020.03.056.

Prevalence of gastric intestinal metaplasia in a multiethnic US veterans population
Nguyen TH et al. Clin Gastroenterol Hepatol. 2021 Feb 1;19(2):269-76. doi: 10.1016/j.cgh.2020.03.015.

Rome IV functional gastrointestinal disorders and health impairment in subjects with hypermobility spectrum disorders or hypermobile Ehlers-Danlos syndrome
Lam CY et al. Clin Gastroenterol Hepatol. 2021 Feb 1;19(2):277-87. doi: 10.1016/j.cgh.2020.02.034.

Factors that affect adequacy of colon cleansing for colonoscopy in hospitalized patients
Fucci L et al. Clin Gastroenterol Hepatol. 2021 Feb 1;19(2):339-48. doi: org/10.1016/j.cgh.2020.02.055.


March 2021

Real-world gluten exposure in patients with celiac disease on gluten-free diets, determined from gliadin immunogenic peptides in urine and fecal samples
Stefanolo JP et al. Clin Gastroenterol Hepatol. 2021 Mar 1;19(3):484-91. doi: 10.1016/j.cgh.2020.03.038.



Factors associated with response to anorectal biofeedback therapy in patients with fecal incontinence

Mazor Y et al. Clin Gastroenterol Hepatol. 2021 Mar 1;19(3):492-502. doi: 10.1016/j.cgh.2020.03.050.



April 2021

Long-term outcome of gastric per-oral endoscopic pyloromyotomy in treatment of gastroparesis

Abdelfatah MM et al. Clin Gastroenterol Hepatol. 2021 Apr 1;19(4):816-24. doi: 10.1016/j.cgh.2020.05.039.



What gastroenterologists should know about COVID-19 vaccines

Rolak S et al. Clin Gastroenterol Hepatol. 2021 Apr 1;19(4):657-61. doi: 10.1016/j.cgh.2021.01.001.



No benefit of concomitant immunomodulator therapy on efficacy of biologics that are not tumor necrosis factor antagonists in patients with inflammatory bowel diseases: A meta-analysis

Yzet C et al. Clin Gastroenterol Hepatol. 2021 Apr 1;19(4):668-78. doi: 10.1016/j.cgh.2020.06.071.



Patient safety reporting in GI: All hands on deck

Wall A and Kothari D. Clin Gastroenterol Hepatol. 2021 Apr 1;19(4):626-32. doi: 10.1016/j.cgh.2020.11.007.

Techniques and Innovations in Gastrointestinal Endoscopy

Barriers and pitfalls for artificial intelligence in gastroenterology: Ethical and regulatory issues

Ahmad OF et al. Tech Innov Gastrointest Endosc. 2020 Apr 1;22(2):80-4. doi: 10.1016/j.tgie.2019.150636.



Development of a scoring system to predict a positive diagnosis on video capsule endoscopy for suspected small bowel bleeding

Marya NB et al. Tech Innov Gastrointest Endosc. 2020 Oct 1;22(4):178-84. doi: 10.1016/j.tige.2020.06.001.



Training for Advanced Endoscopic Imaging in Gastrointestinal Diseases

Hoogenboom SA et al. Tech Innov Gastrointest Endosc. 2021 Jan 1;23(1):99-106. doi: 10.1016/j.tige.2020.09.001.



Chromoendoscopy techniques in imaging of colorectal polyps and cancer: Overview and practical applications for detection and characterization.

Rivero-Sanchez L et al. Tech Innov Gastrointest Endosc. 2021 Jan 1;23(1):30-41. doi: 10.1016/j.tige.2020.10.006.




 

Gastroenterology

February 2021

Worldwide burden of, risk factors for, and trends in pancreatic cancer
Huang J et al. Gastroenterology. 2021 Mar 1;160(4):744-54. doi: 10.1053/j.gastro.2020.10.007.

Fibrates for Itch (FITCH) in fibrosing cholangiopathies: A double-blind, randomized, placebo-controlled trial
de Vries E et al. Gastroenterology. 2021 Mar 1;160(4):734-43.e6. doi: 10.1053/j.gastro.2020.10.001.



March 2021

How to integrate a medical ethics curriculum into gastroenterology fellowships
Rao VL et al. Gastroenterology. 2021 Mar 1;160(4):1003-6. https://doi.org/10.1053/j.gastro.2021.01.211.

Colonoscopist performance and colorectal cancer risk after adenoma removal to stratify surveillance: two nationwide observational studies
Wieszczy P et al. Gastroenterology. 2021 Mar 1;160(4):1067-74. doi: 10.1053/j.gastro.2020.10.009.

Pregnancy and neonatal outcomes after fetal exposure to biologics and thiopurines among women with inflammatory bowel disease
Mahadevan U et al. Gastroenterology. 2021 Mar 1;160(4):1131-9. doi: 10.1053/j.gastro.2020.11.038.


April 2021

AGA Clinical Practice Guidelines on intragastric balloons in the management of obesity
Muniraj T et al. Gastroenterology. 2021 Apr 1;160(5):1799-808. doi: 10.1053/j.gastro.2021.03.003.

How to strategically build your network for early career gastroenterologists
Gaidos JKJ et al. Gastroenterology. 2021 Apr 1;160(5):1461-6. doi: 10.1053/j.gastro.2021.01.025.

The microbiota-gut-brain axis: From motility to mood
Margolis KG et al. Gastroenterology. 2021 Apr 1;160(5):1486-501. doi: 10.1053/j.gastro.2020.10.066.

The association of histologic and noninvasive tests with adverse clinical and patient-reported outcomes in patients with advanced fibrosis due to nonalcoholic steatohepatitis
Younossi ZM et al. Gastroenterology. 2021 Apr 1;160(5):1608-19. doi: 10.1053/j.gastro.2020.12.003.
 

Clinical Gastroenterology and Hepatology

February 2021

Management of chronic abdominal distension and bloating
Lacy BE et al. Clin Gastroenterol Hepatol. 2021 Feb 1;19(2):219-31. doi: 10.1016/j.cgh.2020.03.056.

Prevalence of gastric intestinal metaplasia in a multiethnic US veterans population
Nguyen TH et al. Clin Gastroenterol Hepatol. 2021 Feb 1;19(2):269-76. doi: 10.1016/j.cgh.2020.03.015.

Rome IV functional gastrointestinal disorders and health impairment in subjects with hypermobility spectrum disorders or hypermobile Ehlers-Danlos syndrome
Lam CY et al. Clin Gastroenterol Hepatol. 2021 Feb 1;19(2):277-87. doi: 10.1016/j.cgh.2020.02.034.

Factors that affect adequacy of colon cleansing for colonoscopy in hospitalized patients
Fucci L et al. Clin Gastroenterol Hepatol. 2021 Feb 1;19(2):339-48. doi: org/10.1016/j.cgh.2020.02.055.


March 2021

Real-world gluten exposure in patients with celiac disease on gluten-free diets, determined from gliadin immunogenic peptides in urine and fecal samples
Stefanolo JP et al. Clin Gastroenterol Hepatol. 2021 Mar 1;19(3):484-91. doi: 10.1016/j.cgh.2020.03.038.



Factors associated with response to anorectal biofeedback therapy in patients with fecal incontinence

Mazor Y et al. Clin Gastroenterol Hepatol. 2021 Mar 1;19(3):492-502. doi: 10.1016/j.cgh.2020.03.050.



April 2021

Long-term outcome of gastric per-oral endoscopic pyloromyotomy in treatment of gastroparesis

Abdelfatah MM et al. Clin Gastroenterol Hepatol. 2021 Apr 1;19(4):816-24. doi: 10.1016/j.cgh.2020.05.039.



What gastroenterologists should know about COVID-19 vaccines

Rolak S et al. Clin Gastroenterol Hepatol. 2021 Apr 1;19(4):657-61. doi: 10.1016/j.cgh.2021.01.001.



No benefit of concomitant immunomodulator therapy on efficacy of biologics that are not tumor necrosis factor antagonists in patients with inflammatory bowel diseases: A meta-analysis

Yzet C et al. Clin Gastroenterol Hepatol. 2021 Apr 1;19(4):668-78. doi: 10.1016/j.cgh.2020.06.071.



Patient safety reporting in GI: All hands on deck

Wall A and Kothari D. Clin Gastroenterol Hepatol. 2021 Apr 1;19(4):626-32. doi: 10.1016/j.cgh.2020.11.007.

Techniques and Innovations in Gastrointestinal Endoscopy

Barriers and pitfalls for artificial intelligence in gastroenterology: Ethical and regulatory issues

Ahmad OF et al. Tech Innov Gastrointest Endosc. 2020 Apr 1;22(2):80-4. doi: 10.1016/j.tgie.2019.150636.



Development of a scoring system to predict a positive diagnosis on video capsule endoscopy for suspected small bowel bleeding

Marya NB et al. Tech Innov Gastrointest Endosc. 2020 Oct 1;22(4):178-84. doi: 10.1016/j.tige.2020.06.001.



Training for Advanced Endoscopic Imaging in Gastrointestinal Diseases

Hoogenboom SA et al. Tech Innov Gastrointest Endosc. 2021 Jan 1;23(1):99-106. doi: 10.1016/j.tige.2020.09.001.



Chromoendoscopy techniques in imaging of colorectal polyps and cancer: Overview and practical applications for detection and characterization.

Rivero-Sanchez L et al. Tech Innov Gastrointest Endosc. 2021 Jan 1;23(1):30-41. doi: 10.1016/j.tige.2020.10.006.