The New Gastroenterologist

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.

 

 

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.

 

 

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.

 

 

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.

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.




 

Each year in the month of March, advocates, physicians, and health care educators come together to promote the importance of colorectal cancer screening during Colorectal Cancer Awareness Month. As independent GI physicians, we work within our communities to promote colorectal screening year-round.

We also understand that our education efforts do not end with the people in our community who need to be screened. Independent GI practices also engage with primary care physicians who often initiate conversations about available screening tests and when people should be screened.

Colorectal cancer (CRC) is the second leading cause of cancer death in the United States.¹ It is expected to kill more than 50,000 Americans this year alone.² This is why screening for colorectal cancer is so important. The American Cancer Society recommends screening for all average-risk patients aged 45-75 years.³

The good news? If caught early, the survival rate is very high. In fact, when caught early, the five-year survival rate is 90 percent. Unfortunately, one in three Americans who are eligible for screenings do not get screened. For certain groups, there are larger numbers of people who are not getting screened. And there are groups for whom the death rates from colorectal cancer are much higher.
 

Disparities in colorectal cancer screenings

According to the American Cancer Society, Blacks and Hispanics are less likely to receive prompt follow up after an abnormal CRC screening result and are more likely to be diagnosed with late-stage cancer.⁴ African Americans have the highest death rate when compared with all other racial groups in the United States. American Indians and Alaska Natives are the only groups for which CRC death rates are not declining.

There are many factors that drive disparities, but the main factors seem to be socioeconomic status and differences in access to early detection and treatment. While some of these issues are complex and difficult to change, increasing awareness and providing education can be easier than you might think.
 

Working with your community as a private GI practitioner

To address economic factors, Atlanta Gastroenterology Associates has a program that provides resources on a sliding fee scale to people in our community who do not have insurance and are concerned about having to pay for CRC screening out of pocket. This includes the costs for anesthesia, colonoscopy, and pathology services.

We also have a Direct Access Program, which allows people to self-schedule a screening and fill out a survey that assesses their candidacy for screening colonoscopy. This allows our patients to bypass an initial prescreening office visit and associated copays. Patients are provided instructions for colonoscopy prep and show up for the colonoscopy on the day of their procedure. When the colonoscopy is completed, we give them a patient education card on CRC screening to share with friends and family members who need to be screened.

Atlanta is a very diverse city, and representation is important. But, fortunately, the size of Atlanta Gastroenterology Associates allows us to have representation within many communities. We attend a significant number of health fairs and community events, many of which are sourced internally. Our physicians and staff are members of churches and social groups that we work with to provide screening materials and conduct informational events.

Word of mouth is the best advertising, and it works the same way with health education. There are a lot of myths that we must debunk. And in many of our communities, people are worrying about paying the bills to keep the lights on – they are not thinking about getting screened. But, if they hear from a friend or family member that their screening colonoscopy was a good experience and that resources were provided to help pay for the procedure, it really does make a difference.

You do not need to join a large practice to have an impact. All over the country, there are community groups working to increase screening rates, and engaging with those groups is a good start. During the COVID-19 pandemic, we are all using social media and other platforms to connect. You do not need a lot of resources to set up a Zoom meeting with people in your community to discuss CRC screening.
 

Engaging with referring physicians

As a private practice practitioner, part of growing your practice is engaging with the primary care physicians in your area to ensure that they are up to date on the latest research in CRC screening and that they are discussing available screening options with their patients.

Preventing cancer should always be our first goal. Most CRCs begin as a polyp. Finding, quantifying, localizing, and removing polyps through screening colonoscopy is the most effective strategy for preventing this cancer. That is why colonoscopy remains the preferred method for colon cancer screening.

The Multi-Society Task Force on Colorectal Cancer recommends that, in sequential approaches, physicians should offer colonoscopy first.⁵ For patients who decline to have a colonoscopy, the FIT test should be offered next, followed by second-tier tests such as Cologuard and CT colonography for patients who decline both first-tier options.

Beyond the science of colorectal screening, we want to make sure that our primary care partners are aware of the disparities that exist – and which patients are at higher risk – so that they can engage with their patients to encourage screening.

For example, in our practice, we work with local Asian American community groups to help make sure that the “model minority” myth – that Asian Americans are healthier, wealthier, and better educated than the average American – does not become a barrier to screening. While Asian Americans may have lower overall rates of some types of cancer, there are some cancers that disproportionately affect certain Asian American groups. Rates of CRC in Japanese men, for instance, are 23% higher than in non-Hispanic Whites.

Additionally, we work with our primary care colleagues to help them understand that patients may have insurance considerations when choosing a test. While insurance typically covers 100% of a preventive screening test, a follow-up colonoscopy for a positive stool test is considered a diagnostic or therapeutic service and may not be fully covered. Medicare patients may face a coinsurance bill after their follow-up colonoscopy for a positive stool test. Legislation was passed last year to remove this barrier, but Medicare beneficiaries may have some out-of-pocket costs until it is completely removed in 2030.
 

Are you joining a practice that supports CRC education? Just ask!

We all want to work for an organization that aligns with our core values, and for GI physicians like us, CRC screening is a core component of our everyday work.

If you are considering joining a private practice, ask how the practice is doing with their CRC awareness programs and if it leads to increases in screenings. Inquire about the groups that are being engaged with and why. Is the practice focused on communities that have disparities in screening and treatment, and is it able to complete the entire screening process for individuals in communities that are more adversely affected by colorectal cancer?

We have found that candidates who have the most success in our practice are people who want to work at Atlanta Gastroenterology Associates but are also active in their communities and have a sense of how they want to be of service in their community. It is a sign of leadership in people – the idea that they are really going to get out and network and build a practice that serves everyone in their community. These actions make a difference in getting more people screened and in decreasing the disparities that exist.

Dr. Aja McCutchen is the chair of the quality committee at Atlanta Gastroenterology Associates and serves as chair of the Digestive Health Physicians Association’s Diversity, Equity and Inclusion Committee. She reports having nothing to disclose.

References

1. Siegel RL et al. CA Cancer J Clin. 2018 Jan;68(1):7-30.

2. Key Statistics for Colorectal Cancer. Cancer.org.

3. Wolf AMD et al. CA Cancer J Clin. 2018 Jul;68(4):250-281.

4. American Cancer Society. Colorectal Cancer Facts & Figures 2020-2022.

5. Rex DK et al. Am J Gastroenterol. 2017;112(7):1016-30.

Each year in the month of March, advocates, physicians, and health care educators come together to promote the importance of colorectal cancer screening during Colorectal Cancer Awareness Month. As independent GI physicians, we work within our communities to promote colorectal screening year-round.

We also understand that our education efforts do not end with the people in our community who need to be screened. Independent GI practices also engage with primary care physicians who often initiate conversations about available screening tests and when people should be screened.

Colorectal cancer (CRC) is the second leading cause of cancer death in the United States.¹ It is expected to kill more than 50,000 Americans this year alone.² This is why screening for colorectal cancer is so important. The American Cancer Society recommends screening for all average-risk patients aged 45-75 years.³

The good news? If caught early, the survival rate is very high. In fact, when caught early, the five-year survival rate is 90 percent. Unfortunately, one in three Americans who are eligible for screenings do not get screened. For certain groups, there are larger numbers of people who are not getting screened. And there are groups for whom the death rates from colorectal cancer are much higher.
 

Disparities in colorectal cancer screenings

According to the American Cancer Society, Blacks and Hispanics are less likely to receive prompt follow up after an abnormal CRC screening result and are more likely to be diagnosed with late-stage cancer.⁴ African Americans have the highest death rate when compared with all other racial groups in the United States. American Indians and Alaska Natives are the only groups for which CRC death rates are not declining.

There are many factors that drive disparities, but the main factors seem to be socioeconomic status and differences in access to early detection and treatment. While some of these issues are complex and difficult to change, increasing awareness and providing education can be easier than you might think.
 

Working with your community as a private GI practitioner

To address economic factors, Atlanta Gastroenterology Associates has a program that provides resources on a sliding fee scale to people in our community who do not have insurance and are concerned about having to pay for CRC screening out of pocket. This includes the costs for anesthesia, colonoscopy, and pathology services.

We also have a Direct Access Program, which allows people to self-schedule a screening and fill out a survey that assesses their candidacy for screening colonoscopy. This allows our patients to bypass an initial prescreening office visit and associated copays. Patients are provided instructions for colonoscopy prep and show up for the colonoscopy on the day of their procedure. When the colonoscopy is completed, we give them a patient education card on CRC screening to share with friends and family members who need to be screened.

Atlanta is a very diverse city, and representation is important. But, fortunately, the size of Atlanta Gastroenterology Associates allows us to have representation within many communities. We attend a significant number of health fairs and community events, many of which are sourced internally. Our physicians and staff are members of churches and social groups that we work with to provide screening materials and conduct informational events.

Word of mouth is the best advertising, and it works the same way with health education. There are a lot of myths that we must debunk. And in many of our communities, people are worrying about paying the bills to keep the lights on – they are not thinking about getting screened. But, if they hear from a friend or family member that their screening colonoscopy was a good experience and that resources were provided to help pay for the procedure, it really does make a difference.

You do not need to join a large practice to have an impact. All over the country, there are community groups working to increase screening rates, and engaging with those groups is a good start. During the COVID-19 pandemic, we are all using social media and other platforms to connect. You do not need a lot of resources to set up a Zoom meeting with people in your community to discuss CRC screening.
 

Engaging with referring physicians

As a private practice practitioner, part of growing your practice is engaging with the primary care physicians in your area to ensure that they are up to date on the latest research in CRC screening and that they are discussing available screening options with their patients.

Preventing cancer should always be our first goal. Most CRCs begin as a polyp. Finding, quantifying, localizing, and removing polyps through screening colonoscopy is the most effective strategy for preventing this cancer. That is why colonoscopy remains the preferred method for colon cancer screening.

The Multi-Society Task Force on Colorectal Cancer recommends that, in sequential approaches, physicians should offer colonoscopy first.⁵ For patients who decline to have a colonoscopy, the FIT test should be offered next, followed by second-tier tests such as Cologuard and CT colonography for patients who decline both first-tier options.

Beyond the science of colorectal screening, we want to make sure that our primary care partners are aware of the disparities that exist – and which patients are at higher risk – so that they can engage with their patients to encourage screening.

For example, in our practice, we work with local Asian American community groups to help make sure that the “model minority” myth – that Asian Americans are healthier, wealthier, and better educated than the average American – does not become a barrier to screening. While Asian Americans may have lower overall rates of some types of cancer, there are some cancers that disproportionately affect certain Asian American groups. Rates of CRC in Japanese men, for instance, are 23% higher than in non-Hispanic Whites.

Additionally, we work with our primary care colleagues to help them understand that patients may have insurance considerations when choosing a test. While insurance typically covers 100% of a preventive screening test, a follow-up colonoscopy for a positive stool test is considered a diagnostic or therapeutic service and may not be fully covered. Medicare patients may face a coinsurance bill after their follow-up colonoscopy for a positive stool test. Legislation was passed last year to remove this barrier, but Medicare beneficiaries may have some out-of-pocket costs until it is completely removed in 2030.
 

Are you joining a practice that supports CRC education? Just ask!

We all want to work for an organization that aligns with our core values, and for GI physicians like us, CRC screening is a core component of our everyday work.

If you are considering joining a private practice, ask how the practice is doing with their CRC awareness programs and if it leads to increases in screenings. Inquire about the groups that are being engaged with and why. Is the practice focused on communities that have disparities in screening and treatment, and is it able to complete the entire screening process for individuals in communities that are more adversely affected by colorectal cancer?

We have found that candidates who have the most success in our practice are people who want to work at Atlanta Gastroenterology Associates but are also active in their communities and have a sense of how they want to be of service in their community. It is a sign of leadership in people – the idea that they are really going to get out and network and build a practice that serves everyone in their community. These actions make a difference in getting more people screened and in decreasing the disparities that exist.

Dr. Aja McCutchen is the chair of the quality committee at Atlanta Gastroenterology Associates and serves as chair of the Digestive Health Physicians Association’s Diversity, Equity and Inclusion Committee. She reports having nothing to disclose.

References

1. Siegel RL et al. CA Cancer J Clin. 2018 Jan;68(1):7-30.

2. Key Statistics for Colorectal Cancer. Cancer.org.

3. Wolf AMD et al. CA Cancer J Clin. 2018 Jul;68(4):250-281.

4. American Cancer Society. Colorectal Cancer Facts & Figures 2020-2022.

5. Rex DK et al. Am J Gastroenterol. 2017;112(7):1016-30.

Each year in the month of March, advocates, physicians, and health care educators come together to promote the importance of colorectal cancer screening during Colorectal Cancer Awareness Month. As independent GI physicians, we work within our communities to promote colorectal screening year-round.

We also understand that our education efforts do not end with the people in our community who need to be screened. Independent GI practices also engage with primary care physicians who often initiate conversations about available screening tests and when people should be screened.

Colorectal cancer (CRC) is the second leading cause of cancer death in the United States.¹ It is expected to kill more than 50,000 Americans this year alone.² This is why screening for colorectal cancer is so important. The American Cancer Society recommends screening for all average-risk patients aged 45-75 years.³

The good news? If caught early, the survival rate is very high. In fact, when caught early, the five-year survival rate is 90 percent. Unfortunately, one in three Americans who are eligible for screenings do not get screened. For certain groups, there are larger numbers of people who are not getting screened. And there are groups for whom the death rates from colorectal cancer are much higher.
 

Disparities in colorectal cancer screenings

According to the American Cancer Society, Blacks and Hispanics are less likely to receive prompt follow up after an abnormal CRC screening result and are more likely to be diagnosed with late-stage cancer.⁴ African Americans have the highest death rate when compared with all other racial groups in the United States. American Indians and Alaska Natives are the only groups for which CRC death rates are not declining.

There are many factors that drive disparities, but the main factors seem to be socioeconomic status and differences in access to early detection and treatment. While some of these issues are complex and difficult to change, increasing awareness and providing education can be easier than you might think.
 

Working with your community as a private GI practitioner

To address economic factors, Atlanta Gastroenterology Associates has a program that provides resources on a sliding fee scale to people in our community who do not have insurance and are concerned about having to pay for CRC screening out of pocket. This includes the costs for anesthesia, colonoscopy, and pathology services.

We also have a Direct Access Program, which allows people to self-schedule a screening and fill out a survey that assesses their candidacy for screening colonoscopy. This allows our patients to bypass an initial prescreening office visit and associated copays. Patients are provided instructions for colonoscopy prep and show up for the colonoscopy on the day of their procedure. When the colonoscopy is completed, we give them a patient education card on CRC screening to share with friends and family members who need to be screened.

Atlanta is a very diverse city, and representation is important. But, fortunately, the size of Atlanta Gastroenterology Associates allows us to have representation within many communities. We attend a significant number of health fairs and community events, many of which are sourced internally. Our physicians and staff are members of churches and social groups that we work with to provide screening materials and conduct informational events.

Word of mouth is the best advertising, and it works the same way with health education. There are a lot of myths that we must debunk. And in many of our communities, people are worrying about paying the bills to keep the lights on – they are not thinking about getting screened. But, if they hear from a friend or family member that their screening colonoscopy was a good experience and that resources were provided to help pay for the procedure, it really does make a difference.

You do not need to join a large practice to have an impact. All over the country, there are community groups working to increase screening rates, and engaging with those groups is a good start. During the COVID-19 pandemic, we are all using social media and other platforms to connect. You do not need a lot of resources to set up a Zoom meeting with people in your community to discuss CRC screening.
 

Engaging with referring physicians

As a private practice practitioner, part of growing your practice is engaging with the primary care physicians in your area to ensure that they are up to date on the latest research in CRC screening and that they are discussing available screening options with their patients.

Preventing cancer should always be our first goal. Most CRCs begin as a polyp. Finding, quantifying, localizing, and removing polyps through screening colonoscopy is the most effective strategy for preventing this cancer. That is why colonoscopy remains the preferred method for colon cancer screening.

The Multi-Society Task Force on Colorectal Cancer recommends that, in sequential approaches, physicians should offer colonoscopy first.⁵ For patients who decline to have a colonoscopy, the FIT test should be offered next, followed by second-tier tests such as Cologuard and CT colonography for patients who decline both first-tier options.

Beyond the science of colorectal screening, we want to make sure that our primary care partners are aware of the disparities that exist – and which patients are at higher risk – so that they can engage with their patients to encourage screening.

For example, in our practice, we work with local Asian American community groups to help make sure that the “model minority” myth – that Asian Americans are healthier, wealthier, and better educated than the average American – does not become a barrier to screening. While Asian Americans may have lower overall rates of some types of cancer, there are some cancers that disproportionately affect certain Asian American groups. Rates of CRC in Japanese men, for instance, are 23% higher than in non-Hispanic Whites.

Additionally, we work with our primary care colleagues to help them understand that patients may have insurance considerations when choosing a test. While insurance typically covers 100% of a preventive screening test, a follow-up colonoscopy for a positive stool test is considered a diagnostic or therapeutic service and may not be fully covered. Medicare patients may face a coinsurance bill after their follow-up colonoscopy for a positive stool test. Legislation was passed last year to remove this barrier, but Medicare beneficiaries may have some out-of-pocket costs until it is completely removed in 2030.
 

Are you joining a practice that supports CRC education? Just ask!

We all want to work for an organization that aligns with our core values, and for GI physicians like us, CRC screening is a core component of our everyday work.

If you are considering joining a private practice, ask how the practice is doing with their CRC awareness programs and if it leads to increases in screenings. Inquire about the groups that are being engaged with and why. Is the practice focused on communities that have disparities in screening and treatment, and is it able to complete the entire screening process for individuals in communities that are more adversely affected by colorectal cancer?

We have found that candidates who have the most success in our practice are people who want to work at Atlanta Gastroenterology Associates but are also active in their communities and have a sense of how they want to be of service in their community. It is a sign of leadership in people – the idea that they are really going to get out and network and build a practice that serves everyone in their community. These actions make a difference in getting more people screened and in decreasing the disparities that exist.

Dr. Aja McCutchen is the chair of the quality committee at Atlanta Gastroenterology Associates and serves as chair of the Digestive Health Physicians Association’s Diversity, Equity and Inclusion Committee. She reports having nothing to disclose.

References

1. Siegel RL et al. CA Cancer J Clin. 2018 Jan;68(1):7-30.

2. Key Statistics for Colorectal Cancer. Cancer.org.

3. Wolf AMD et al. CA Cancer J Clin. 2018 Jul;68(4):250-281.

4. American Cancer Society. Colorectal Cancer Facts & Figures 2020-2022.

5. Rex DK et al. Am J Gastroenterol. 2017;112(7):1016-30.

Abdominal pain is a commonly seen presenting concern in gastroenterology clinics. Establishing a diagnosis effectively and efficiently can be challenging given the broad differential. Abdominal wall pain is an often-overlooked diagnosis but accounts for up to 30% of cases of chronic abdominal pain¹ and up to 10% of patients with chronic idiopathic abdominal pain seen in gastroenterology practices.² Trigger point injection in the office can be both diagnostic and therapeutic.

The prevalence of chronic abdominal wall pain is highest in the fifth and sixth decades, and it is four times more likely to occur in women than in men. Common comorbid conditions include obesity, gastroesophageal reflux disease, irritable bowel syndrome, and fibromyalgia.³ Abdominal wall pain is often sharp or burning due to somatic innervation of the abdominal wall supplied by the anterior branches of thoracic intercostal nerves (T7 to T11). Abdominal wall pain may originate from entrapment of these nerves.² Potential causes of entrapment include disruption of insulating fat, localized edema and distension, and scar tissue or fibrosis from prior surgical procedures.³ Symptoms are typically exacerbated with any actions or activities that engage the abdominal wall such as twisting or turning, and pain often improves with rest.

The classic physical exam finding for abdominal wall pain is a positive Carnett sign. This is determined via palpation of the point of maximal tenderness. First, this is done with a single finger while the patient’s abdominal wall is relaxed. The same point is then palpated again while the patient engages their abdominal muscles, most commonly while the patient to performs a “sit up” or lifts their legs off the exam table. Exacerbation of pain with these maneuvers indicates a positive test and suggests the abdominal wall as the underlying etiology.

While performing the maneuver for determining Carnett sign is a simple test in the traditional office visit, the COVID-19 pandemic has led to a burgeoning proportion of telehealth visits, limiting the physician’s ability to perform a direct physical exam. Fortunately, the maneuvers required when testing for Carnett sign are simple enough that a clinician can guide a patient step-by-step on how to perform the test. Ideally, if a family member or friend is available to serve as the clinician’s hands, the test can be performed with ease while directly visualizing proper technique. Sample videos of how the test is performed are readily available on the Internet for patients to view (the authors suggest screening the video yourself before providing a link to patients). The sensitivity and specificity of Carnett sign are very high (>70%) and even better when there is no apparent hernia.¹
 

Management

Trigger point injections with local anesthetic can be both diagnostic and therapeutic in patients with abdominal wall pain. An immediate reduction of pain by at least 50% with injection at the site of maximal tenderness strongly supports the diagnosis of abdominal wall pain.¹ Patients should first be thoroughly counseled on potential side effects of local corticosteroid injection to include risk of infection, bleeding, pain, skin hypopigmentation, or thinning and fat atrophy. Repeat injections are rarely needed, and any additional injection should be performed after at least 3 months. Additional adjunct therapies include nonsteroidal anti-inflammatory medications, topical therapies such as lidocaine, and neuroleptic agents such as gabapentin.⁴ One previously described trigger point injection technique, involves a mix of triamcinolone and lidocaine injected at the point of maximal tenderness.⁵ This technique is easy to perform in clinic and has minimal risks.

Conclusion

Abdominal wall pain is a common, yet often-overlooked, condition that can be diagnosed with a good clinical history and physical exam. A simple in-office trigger point injection can confirm the diagnosis and offer durable relief for most patients. A shift to virtual medicine does not need to a barrier to diagnosis, particularly in the attentive patient.

Dr. Park is a fellow in the gastroenterology service in the Department of Internal Medicine at Naval Medical Center San Diego and an assistant professor in the department of medicine of the Uniformed Services University in Bethesda, Md. Dr. Singla is a gastroenterologist at Capital Digestive Care in Silver Spring, Md., and an associate professor in the department of medicine at the Uniformed Services University. The authors have no conflicts of interest.

References

1. Glissen Brown JR et al. J Clin Gastroenterol. 2016;50(10):828-35.

2. Srinivasan R, Greenbaum DS. Am J Gastroenterol. 2002;97(4):824-30.

3. Kambox AK et al. Mayo Clin Proc. 2019;94(1):139-44.

4. Scheltinga MR, Roumen RM. Hernia. 2018;22(3):507-16.

5. Singla M, Laczek JT. Am J Gastroenterol. 2020 May;115(5):645-7.

Abdominal pain is a commonly seen presenting concern in gastroenterology clinics. Establishing a diagnosis effectively and efficiently can be challenging given the broad differential. Abdominal wall pain is an often-overlooked diagnosis but accounts for up to 30% of cases of chronic abdominal pain¹ and up to 10% of patients with chronic idiopathic abdominal pain seen in gastroenterology practices.² Trigger point injection in the office can be both diagnostic and therapeutic.

The prevalence of chronic abdominal wall pain is highest in the fifth and sixth decades, and it is four times more likely to occur in women than in men. Common comorbid conditions include obesity, gastroesophageal reflux disease, irritable bowel syndrome, and fibromyalgia.³ Abdominal wall pain is often sharp or burning due to somatic innervation of the abdominal wall supplied by the anterior branches of thoracic intercostal nerves (T7 to T11). Abdominal wall pain may originate from entrapment of these nerves.² Potential causes of entrapment include disruption of insulating fat, localized edema and distension, and scar tissue or fibrosis from prior surgical procedures.³ Symptoms are typically exacerbated with any actions or activities that engage the abdominal wall such as twisting or turning, and pain often improves with rest.

The classic physical exam finding for abdominal wall pain is a positive Carnett sign. This is determined via palpation of the point of maximal tenderness. First, this is done with a single finger while the patient’s abdominal wall is relaxed. The same point is then palpated again while the patient engages their abdominal muscles, most commonly while the patient to performs a “sit up” or lifts their legs off the exam table. Exacerbation of pain with these maneuvers indicates a positive test and suggests the abdominal wall as the underlying etiology.

While performing the maneuver for determining Carnett sign is a simple test in the traditional office visit, the COVID-19 pandemic has led to a burgeoning proportion of telehealth visits, limiting the physician’s ability to perform a direct physical exam. Fortunately, the maneuvers required when testing for Carnett sign are simple enough that a clinician can guide a patient step-by-step on how to perform the test. Ideally, if a family member or friend is available to serve as the clinician’s hands, the test can be performed with ease while directly visualizing proper technique. Sample videos of how the test is performed are readily available on the Internet for patients to view (the authors suggest screening the video yourself before providing a link to patients). The sensitivity and specificity of Carnett sign are very high (>70%) and even better when there is no apparent hernia.¹
 

Management

Trigger point injections with local anesthetic can be both diagnostic and therapeutic in patients with abdominal wall pain. An immediate reduction of pain by at least 50% with injection at the site of maximal tenderness strongly supports the diagnosis of abdominal wall pain.¹ Patients should first be thoroughly counseled on potential side effects of local corticosteroid injection to include risk of infection, bleeding, pain, skin hypopigmentation, or thinning and fat atrophy. Repeat injections are rarely needed, and any additional injection should be performed after at least 3 months. Additional adjunct therapies include nonsteroidal anti-inflammatory medications, topical therapies such as lidocaine, and neuroleptic agents such as gabapentin.⁴ One previously described trigger point injection technique, involves a mix of triamcinolone and lidocaine injected at the point of maximal tenderness.⁵ This technique is easy to perform in clinic and has minimal risks.

Conclusion

Abdominal wall pain is a common, yet often-overlooked, condition that can be diagnosed with a good clinical history and physical exam. A simple in-office trigger point injection can confirm the diagnosis and offer durable relief for most patients. A shift to virtual medicine does not need to a barrier to diagnosis, particularly in the attentive patient.

Dr. Park is a fellow in the gastroenterology service in the Department of Internal Medicine at Naval Medical Center San Diego and an assistant professor in the department of medicine of the Uniformed Services University in Bethesda, Md. Dr. Singla is a gastroenterologist at Capital Digestive Care in Silver Spring, Md., and an associate professor in the department of medicine at the Uniformed Services University. The authors have no conflicts of interest.

References

1. Glissen Brown JR et al. J Clin Gastroenterol. 2016;50(10):828-35.

2. Srinivasan R, Greenbaum DS. Am J Gastroenterol. 2002;97(4):824-30.

3. Kambox AK et al. Mayo Clin Proc. 2019;94(1):139-44.

4. Scheltinga MR, Roumen RM. Hernia. 2018;22(3):507-16.

5. Singla M, Laczek JT. Am J Gastroenterol. 2020 May;115(5):645-7.

Abdominal pain is a commonly seen presenting concern in gastroenterology clinics. Establishing a diagnosis effectively and efficiently can be challenging given the broad differential. Abdominal wall pain is an often-overlooked diagnosis but accounts for up to 30% of cases of chronic abdominal pain¹ and up to 10% of patients with chronic idiopathic abdominal pain seen in gastroenterology practices.² Trigger point injection in the office can be both diagnostic and therapeutic.

The prevalence of chronic abdominal wall pain is highest in the fifth and sixth decades, and it is four times more likely to occur in women than in men. Common comorbid conditions include obesity, gastroesophageal reflux disease, irritable bowel syndrome, and fibromyalgia.³ Abdominal wall pain is often sharp or burning due to somatic innervation of the abdominal wall supplied by the anterior branches of thoracic intercostal nerves (T7 to T11). Abdominal wall pain may originate from entrapment of these nerves.² Potential causes of entrapment include disruption of insulating fat, localized edema and distension, and scar tissue or fibrosis from prior surgical procedures.³ Symptoms are typically exacerbated with any actions or activities that engage the abdominal wall such as twisting or turning, and pain often improves with rest.

The classic physical exam finding for abdominal wall pain is a positive Carnett sign. This is determined via palpation of the point of maximal tenderness. First, this is done with a single finger while the patient’s abdominal wall is relaxed. The same point is then palpated again while the patient engages their abdominal muscles, most commonly while the patient to performs a “sit up” or lifts their legs off the exam table. Exacerbation of pain with these maneuvers indicates a positive test and suggests the abdominal wall as the underlying etiology.

While performing the maneuver for determining Carnett sign is a simple test in the traditional office visit, the COVID-19 pandemic has led to a burgeoning proportion of telehealth visits, limiting the physician’s ability to perform a direct physical exam. Fortunately, the maneuvers required when testing for Carnett sign are simple enough that a clinician can guide a patient step-by-step on how to perform the test. Ideally, if a family member or friend is available to serve as the clinician’s hands, the test can be performed with ease while directly visualizing proper technique. Sample videos of how the test is performed are readily available on the Internet for patients to view (the authors suggest screening the video yourself before providing a link to patients). The sensitivity and specificity of Carnett sign are very high (>70%) and even better when there is no apparent hernia.¹
 

Management

Trigger point injections with local anesthetic can be both diagnostic and therapeutic in patients with abdominal wall pain. An immediate reduction of pain by at least 50% with injection at the site of maximal tenderness strongly supports the diagnosis of abdominal wall pain.¹ Patients should first be thoroughly counseled on potential side effects of local corticosteroid injection to include risk of infection, bleeding, pain, skin hypopigmentation, or thinning and fat atrophy. Repeat injections are rarely needed, and any additional injection should be performed after at least 3 months. Additional adjunct therapies include nonsteroidal anti-inflammatory medications, topical therapies such as lidocaine, and neuroleptic agents such as gabapentin.⁴ One previously described trigger point injection technique, involves a mix of triamcinolone and lidocaine injected at the point of maximal tenderness.⁵ This technique is easy to perform in clinic and has minimal risks.

Conclusion

Abdominal wall pain is a common, yet often-overlooked, condition that can be diagnosed with a good clinical history and physical exam. A simple in-office trigger point injection can confirm the diagnosis and offer durable relief for most patients. A shift to virtual medicine does not need to a barrier to diagnosis, particularly in the attentive patient.

Dr. Park is a fellow in the gastroenterology service in the Department of Internal Medicine at Naval Medical Center San Diego and an assistant professor in the department of medicine of the Uniformed Services University in Bethesda, Md. Dr. Singla is a gastroenterologist at Capital Digestive Care in Silver Spring, Md., and an associate professor in the department of medicine at the Uniformed Services University. The authors have no conflicts of interest.

References

1. Glissen Brown JR et al. J Clin Gastroenterol. 2016;50(10):828-35.

2. Srinivasan R, Greenbaum DS. Am J Gastroenterol. 2002;97(4):824-30.

3. Kambox AK et al. Mayo Clin Proc. 2019;94(1):139-44.

4. Scheltinga MR, Roumen RM. Hernia. 2018;22(3):507-16.

5. Singla M, Laczek JT. Am J Gastroenterol. 2020 May;115(5):645-7.

Gastroenterology fellowship is an exercise in balance. You are learning your way around different parts of the gastrointestinal tract, both cerebrally and anatomically. You are continuously taking care of patients, in the hospital and in the clinic. You attend all kinds of conferences, didactics, and webinars. And though the hours are long, the work is worth seeing a smile from even one patient for whom you have made a tangible difference in health care. Though these moments are priceless, how often they happen is often limited by access to care, health care disparities, and systemic injustice. Fighting for each one of our patients and their health is difficult for even the most seasoned physician. Training during the middle of a pandemic has brought health care disparities to the forefront; delays in colorectal cancer screening and postponements of nonurgent procedures will have downstream impacts. It was with these thoughts in mind that I decided to participate in AGA (American Gastroenterological Association) Advocacy Day in September 2020 as a gastroenterology fellow.

After close to 20 years of in-person Advocacy Days, the AGA decided to take its advocacy efforts to a virtual platform in the fall of 2020. The country remained in the throes of the worst pandemic it had seen in over a century, and social distancing efforts necessitated a different venue than previous years. This year’s online platform was designed to let individuals involved in gastroenterology health care join each other and discuss policies germane to our patients and our profession.

I have to confess that I did not have significant legislative experience, and I signed up for the virtual Advocacy Day with a sense of slight trepidation. Would I be prepared to talk to experts in the field? What did I know about health care policy on the granular level? How could I get across my message cogently and successfully? All I really knew was that I wanted to get engaged with a group of gastroenterologists early on in my career who were not only vociferous advocates for their patients at the bedside, but who were also able to actively support policy changes that would bring about systemic change.

As it turned out, I had nothing to worry about. This advocacy experience was designed for gastroenterology clinical providers to be able to talk intelligently about topics they knew well – research funding, colonoscopy costs, and different levels of therapy for patients with inflammatory bowel disease, among others. To provide an overview of public policy issues, the AGA prepared a legislative briefing book that allowed us to take a deep dive into these topics. I remember reviewing the issue briefs in detail, understanding that I did not need to be an expert but that familiarity with the issues would be a key component of having a successful meeting. I also completed an online advocacy training module that gave me insight into how and why I could advocate for my profession as a future gastroenterologist. Based on our congressional district and state, we were divided into groups of congressional advocates who would speak to specific congressional staff members. During our meetings, we had legislative staff available to help us navigate the finer points of public policy. Each member of my group chose a topic that was personally relevant to them. Throughout our sessions, we shared personal stories, dove in and out of virtual meeting rooms, and made sure we were clear in what we were advocating for.

As a second-year gastroenterology fellow working at the National Institutes of Health, I chose to focus on digestive diseases research funding for the research community. I talked to the congressional staff members about a patient I had seen earlier that year. He was a man in his mid-30s who was diagnosed with hepatitis C more than 10 years ago and was told, at the time of his diagnosis, that there were no good treatments for him. He had resigned himself to that fact until I saw him in my office and spoke to him about the remarkable advances in liver disease treatment that were made over the past few years. I talked to him about how Hepatitis C was a disease that could now be cured – the relief on his face was clear and only reaffirmed in me the understanding that research in digestive diseases has improved the health of our nation’s population through sustained research efforts in gastrointestinal cancers and other life-altering illnesses.

So what did I take away from this adventure in advocacy? Our role as gastroenterologists can go beyond treating one patient in one office in one hospital system at a time. We can effect change by addressing policies that we know are hurting our patients and their health. The learning curve is made much easier under the excellence of the AGA advocacy staff, who takes the time to gather resources and educate us on the specifics of relevant legislative policies, as well as of the congressional members with whom we are speaking. Our advice was sought after because, after years of training, we were the experts in this field. I was proud to have joined this grassroots network of engaged members to speak to our lawmakers. I can only imagine, in the years to come, how wonderful it would be to do this in person in our nation’s capital.

Dr. Asif is a gastroenterology fellow working with the University of Maryland and National Institutes of Health. He has no conflicts of interest to disclose.

Gastroenterology fellowship is an exercise in balance. You are learning your way around different parts of the gastrointestinal tract, both cerebrally and anatomically. You are continuously taking care of patients, in the hospital and in the clinic. You attend all kinds of conferences, didactics, and webinars. And though the hours are long, the work is worth seeing a smile from even one patient for whom you have made a tangible difference in health care. Though these moments are priceless, how often they happen is often limited by access to care, health care disparities, and systemic injustice. Fighting for each one of our patients and their health is difficult for even the most seasoned physician. Training during the middle of a pandemic has brought health care disparities to the forefront; delays in colorectal cancer screening and postponements of nonurgent procedures will have downstream impacts. It was with these thoughts in mind that I decided to participate in AGA (American Gastroenterological Association) Advocacy Day in September 2020 as a gastroenterology fellow.

After close to 20 years of in-person Advocacy Days, the AGA decided to take its advocacy efforts to a virtual platform in the fall of 2020. The country remained in the throes of the worst pandemic it had seen in over a century, and social distancing efforts necessitated a different venue than previous years. This year’s online platform was designed to let individuals involved in gastroenterology health care join each other and discuss policies germane to our patients and our profession.

I have to confess that I did not have significant legislative experience, and I signed up for the virtual Advocacy Day with a sense of slight trepidation. Would I be prepared to talk to experts in the field? What did I know about health care policy on the granular level? How could I get across my message cogently and successfully? All I really knew was that I wanted to get engaged with a group of gastroenterologists early on in my career who were not only vociferous advocates for their patients at the bedside, but who were also able to actively support policy changes that would bring about systemic change.

As it turned out, I had nothing to worry about. This advocacy experience was designed for gastroenterology clinical providers to be able to talk intelligently about topics they knew well – research funding, colonoscopy costs, and different levels of therapy for patients with inflammatory bowel disease, among others. To provide an overview of public policy issues, the AGA prepared a legislative briefing book that allowed us to take a deep dive into these topics. I remember reviewing the issue briefs in detail, understanding that I did not need to be an expert but that familiarity with the issues would be a key component of having a successful meeting. I also completed an online advocacy training module that gave me insight into how and why I could advocate for my profession as a future gastroenterologist. Based on our congressional district and state, we were divided into groups of congressional advocates who would speak to specific congressional staff members. During our meetings, we had legislative staff available to help us navigate the finer points of public policy. Each member of my group chose a topic that was personally relevant to them. Throughout our sessions, we shared personal stories, dove in and out of virtual meeting rooms, and made sure we were clear in what we were advocating for.

As a second-year gastroenterology fellow working at the National Institutes of Health, I chose to focus on digestive diseases research funding for the research community. I talked to the congressional staff members about a patient I had seen earlier that year. He was a man in his mid-30s who was diagnosed with hepatitis C more than 10 years ago and was told, at the time of his diagnosis, that there were no good treatments for him. He had resigned himself to that fact until I saw him in my office and spoke to him about the remarkable advances in liver disease treatment that were made over the past few years. I talked to him about how Hepatitis C was a disease that could now be cured – the relief on his face was clear and only reaffirmed in me the understanding that research in digestive diseases has improved the health of our nation’s population through sustained research efforts in gastrointestinal cancers and other life-altering illnesses.

So what did I take away from this adventure in advocacy? Our role as gastroenterologists can go beyond treating one patient in one office in one hospital system at a time. We can effect change by addressing policies that we know are hurting our patients and their health. The learning curve is made much easier under the excellence of the AGA advocacy staff, who takes the time to gather resources and educate us on the specifics of relevant legislative policies, as well as of the congressional members with whom we are speaking. Our advice was sought after because, after years of training, we were the experts in this field. I was proud to have joined this grassroots network of engaged members to speak to our lawmakers. I can only imagine, in the years to come, how wonderful it would be to do this in person in our nation’s capital.

Dr. Asif is a gastroenterology fellow working with the University of Maryland and National Institutes of Health. He has no conflicts of interest to disclose.

Gastroenterology fellowship is an exercise in balance. You are learning your way around different parts of the gastrointestinal tract, both cerebrally and anatomically. You are continuously taking care of patients, in the hospital and in the clinic. You attend all kinds of conferences, didactics, and webinars. And though the hours are long, the work is worth seeing a smile from even one patient for whom you have made a tangible difference in health care. Though these moments are priceless, how often they happen is often limited by access to care, health care disparities, and systemic injustice. Fighting for each one of our patients and their health is difficult for even the most seasoned physician. Training during the middle of a pandemic has brought health care disparities to the forefront; delays in colorectal cancer screening and postponements of nonurgent procedures will have downstream impacts. It was with these thoughts in mind that I decided to participate in AGA (American Gastroenterological Association) Advocacy Day in September 2020 as a gastroenterology fellow.

After close to 20 years of in-person Advocacy Days, the AGA decided to take its advocacy efforts to a virtual platform in the fall of 2020. The country remained in the throes of the worst pandemic it had seen in over a century, and social distancing efforts necessitated a different venue than previous years. This year’s online platform was designed to let individuals involved in gastroenterology health care join each other and discuss policies germane to our patients and our profession.

I have to confess that I did not have significant legislative experience, and I signed up for the virtual Advocacy Day with a sense of slight trepidation. Would I be prepared to talk to experts in the field? What did I know about health care policy on the granular level? How could I get across my message cogently and successfully? All I really knew was that I wanted to get engaged with a group of gastroenterologists early on in my career who were not only vociferous advocates for their patients at the bedside, but who were also able to actively support policy changes that would bring about systemic change.

As it turned out, I had nothing to worry about. This advocacy experience was designed for gastroenterology clinical providers to be able to talk intelligently about topics they knew well – research funding, colonoscopy costs, and different levels of therapy for patients with inflammatory bowel disease, among others. To provide an overview of public policy issues, the AGA prepared a legislative briefing book that allowed us to take a deep dive into these topics. I remember reviewing the issue briefs in detail, understanding that I did not need to be an expert but that familiarity with the issues would be a key component of having a successful meeting. I also completed an online advocacy training module that gave me insight into how and why I could advocate for my profession as a future gastroenterologist. Based on our congressional district and state, we were divided into groups of congressional advocates who would speak to specific congressional staff members. During our meetings, we had legislative staff available to help us navigate the finer points of public policy. Each member of my group chose a topic that was personally relevant to them. Throughout our sessions, we shared personal stories, dove in and out of virtual meeting rooms, and made sure we were clear in what we were advocating for.

As a second-year gastroenterology fellow working at the National Institutes of Health, I chose to focus on digestive diseases research funding for the research community. I talked to the congressional staff members about a patient I had seen earlier that year. He was a man in his mid-30s who was diagnosed with hepatitis C more than 10 years ago and was told, at the time of his diagnosis, that there were no good treatments for him. He had resigned himself to that fact until I saw him in my office and spoke to him about the remarkable advances in liver disease treatment that were made over the past few years. I talked to him about how Hepatitis C was a disease that could now be cured – the relief on his face was clear and only reaffirmed in me the understanding that research in digestive diseases has improved the health of our nation’s population through sustained research efforts in gastrointestinal cancers and other life-altering illnesses.

So what did I take away from this adventure in advocacy? Our role as gastroenterologists can go beyond treating one patient in one office in one hospital system at a time. We can effect change by addressing policies that we know are hurting our patients and their health. The learning curve is made much easier under the excellence of the AGA advocacy staff, who takes the time to gather resources and educate us on the specifics of relevant legislative policies, as well as of the congressional members with whom we are speaking. Our advice was sought after because, after years of training, we were the experts in this field. I was proud to have joined this grassroots network of engaged members to speak to our lawmakers. I can only imagine, in the years to come, how wonderful it would be to do this in person in our nation’s capital.

Dr. Asif is a gastroenterology fellow working with the University of Maryland and National Institutes of Health. He has no conflicts of interest to disclose.

On a busy call day, Oviea (a second-year gastroenterology fellow), paused in the hallway to listen to a conversation between an endoscopy nurse and a patient. The nurse was requesting the patient’s permission for a gastroenterology fellow to participate in their care and the patient, well acquainted with the role from prior procedures, immediately agreed. Oviea entered the patient’s room, introduced himself as “Dr. Akpotaire, the gastroenterology fellow,” as he had with hundreds of other patients during his fellowship, and completed the informed consent. The interaction was brief but pleasant. As Oviea was leaving the room, the patient asked: “When will I meet the doctor”?

This question was familiar to Oviea. Despite always introducing himself by title and wearing matching identification, many patients had dismissed his credentials since graduating from medical school. His answer was equally familiar: “I am a doctor, and Dr. X, the supervising physician, will meet you soon.” With the patient seemingly placated, Oviea delivered the consent form to the procedure room. Minutes later, he was surprised to learn that the patient specifically requested that he not be allowed to participate in their care. This in combination with the patient’s initial dismissal of Oviea’s credentials, left a sting. While none of the other team members outwardly questioned the reason for the patient’s change of heart, Oviea continued to wonder if the patient’s decision was because of his race.

Beyond gastroenterology, similar experiences are common in other spheres. The Twitter thread #BlackintheIvory recounts stories of microaggressions and structural racism in medicine and academia. The cumulative toll of these experiences leads to departures of Black physicians including Uché Blackstock, MD;¹ Aysha Khoury, MD, MPH;² Ben Danielson, MD;³ Princess Dennar, MD;⁴ and others.
 

Microaggressions as proxy for bias

The term microaggression was coined by Chester Pierce, MD, the first Black tenured professor at Massachusetts General Hospital in the 1970’s, to describe the frequent, yet subtle dismissals Black Americans experienced in society. Over time, the term has been expanded to include “brief and commonplace daily verbal, behavioral, or environmental indignities, intentional or unintentional, that communicate hostile, derogatory, or negative slights and insults” to any marginalized group.⁵

While the term microaggressions is useful in contextualizing individual experiences, it narrowly focuses on conscious or unconscious interpersonal prejudices. In medicine, this misdirects attention away from the policies and practices that create and reinforce prejudices; these policies and practices do so by systematically excluding underrepresented minority (URM) physicians,⁶ defined by the American Association of Medical Colleges as physicians who are Black, Hispanic, Native Americans, and Alaska Natives,⁷ from the medical workforce. Ultimately, this leads to and exacerbates poor health outcomes for racial and ethnic minority patients.

Microaggressions represent our society’s deepest and oldest biases and are rooted in structural racism, as well as misogyny, homophobia, transphobia, xenophobia, ableism, and other prejudices.⁸ For URM physicians, experiences like the example above are frequently caused by structural racism.
 

Structural racism in medicine

Structural racism refers to the policies, practices, cultural representations, and norms that reinforce inequities by providing privileges to White people at the disadvantage of non-White people.⁹ In 1910, Abraham Flexner, commissioned by the Carnegie Foundation and the American Medical Association, wrote that African American physicians should be trained in hygiene rather than surgery and should primarily serve as “sanitarians” whose purpose was to “protect Whites” from common diseases like tuberculosis.¹⁰ The 1910 Flexner Report also emphasized the importance of prerequisite basic sciences education and recommended that only two of the seven existing Black medical schools remain open because Flexner believed that only these schools had the potential to meet the new requirements for medical education.¹¹ A recent analysis found that, had the other five medical schools affiliated with historically Black colleges and universities remained open, this would have resulted in an additional 33,315 Black medical school graduates by 2019.¹² Structural racism explains why the majority of practicing physicians, medical educators, National Institutes of Health–funded researchers, and hospital executives are White and, similarly, why White patients are overrepresented in clinical trials, have better health outcomes, and live longer lives than several racial and ethnic minority groups.¹³

The murders of Ahmaud Arbery, Breonna Taylor, and George Floyd and the inequitable toll of the COVID-19 pandemic on Black, Hispanic, and Native American people renewed the dialogue regarding structural racism in America. Beyond criminal justice and police reform, the current social justice movement demands that structural racism is examined in all spheres. In medicine and health care, acknowledging the history of exclusion and exploitation of Black people and other URM groups is an important first step, but this must be followed by a commitment to an antiracist future for the benefit of all medical professionals and patients.^14,15

Antiracism as a path forward

Antiracism refers to actions and policies that seek to dismantle structural racism. While individuals can and should engage in antiracist actions, it is equally important for organizations and government to actively participate in this process as well.



Individual and interpersonal levels

Gastroenterologists should advocate an end to racist practices within their organizations (e.g., unjustified use of race-based corrections in diagnostic algorithms and practice guidelines),¹⁶ and interrupt microaggressions and racist actions in real time (e.g., overpolicing of underrepresented groups in health care settings).¹⁷ Gastroenterologists from underrepresented groups may also need to unlearn internalized racism, which is defined as acceptance by members of disadvantaged races of the negative messages about their own abilities and intrinsic worth.¹⁸



Organizational level

Gastroenterology divisions and practices must ensure that the entire workforce, including leadership, reflects the diversity of our country. Underrepresented groups represent 33% of the U.S. population, but only 9.1% of gastroenterology fellows and 10% of gastroenterology faculty are from underrepresented groups.¹⁹ In addition to diversifying the field of gastroenterology through financial and operational support of pipeline educational programs, organizations should also promote the scholarship of URM groups, whose work is often undervalued, and redistribute power by elevating voices that have been historically absent.²⁰ Gastroenterology practices should also collect high-quality patient data disaggregated by demographic factors. Doing so will enable rapid identification of disparate health outcomes by demographic variables and inform interventions to eliminate identified disparities.



Government level

The “Executive Order On Advancing Racial Equity and Support for Underserved Communities Through the Federal Government” issued by President Biden on Jan. 20, 2021, is an example of how government can promote antiracism.²¹ The executive order states that domestic policies cause group inequities and calls for the removal of systemic barriers in current and future domestic policies. The executive order outlines several additional ways to improve equity in current and future policy, including engagement, consultation, and coordination with members of underserved communities. The details outlined in the executive order should serve as the foundation for establishing new standards at the state, county, and city levels as well. Gastroenterologists can influence government by voting for officials at all levels that support and promote these standards.

Conclusion

Beyond calling out microaggressions in real time, we must also interrogate the biases, policies, and practices that support them in medicine and beyond. As Black gastroenterologists who have experienced microaggressions and overt acts of racism, we ground Oviea’s experience in structural racism and offer strategies that individuals, organizations, and governing institutions can adopt toward an antiracist future. This model can be applied to experiences rooted in misogyny, homophobia, transphobia, xenophobia, ableism, and other prejudices.

As a nation, we must make an active and collective choice to address structural racism. In health care, doing so will strengthen communities, enhance the lived experiences of URM physician colleagues, and save patient lives. Gastroenterologists, as trusted health care providers, are uniquely positioned to lead the way.

Dr. Akpotaire is a second-year GI fellow in the division of gastroenterology at the University of Washington, Seattle. Dr. Issaka is an assistant professor with both the Fred Hutchinson Cancer Research Center, Seattle, and the division of gastroenterology at the University of Washington.

References

1. Blackstock U. “Why Black doctors like me are leaving faculty positions in academic medical centers.” STAT News, 2020.

2. Asare JG. “One Doctor Shares Her Story of Racism in Medicine.” Forbes. 2021 Feb 1.

3. Kroman D. “Revered doctor steps down, accusing Seattle Children’s Hospital of racism.” Crosscut. 2020 Dec 31.

4. United States District Court Eastern District of Louisiana. Princess Dennar, M.D. v. The Administrators of the Tulane Educational Fund, 2020.

5. Sue DW. Microaggressions in Everyday Life: Race, Gender, and Sexual Orientation. Hoboken, N.J.: Wiley, 2010.

6. Boyd RW. Lancet. 2019 Jun 22;393(10190):2484-5.

7. AAMC. Diversity in Medicine Facts and Figures 2019. Washington, D.C., 2019.

8. Overland MK et al. PM R. 2019 Sep;11(9):1004-12.

9. Jones CP. Ethn Dis. 2018 Aug 9;28(Suppl 1):231-4.

10. Hlavinka E. “Racial Bias in Flexner Report Permeates Medical Education Today.” Medpage Today. 2020 Jun 18.

11. Flexner A. Medical Education in the United States and Canada. New York: 1910. Republished: Bull World Health Organ. 2002;80(7):594-602.

12. Campbell KM et al. JAMA Netw Open. 2020 Aug 3;3(8):e2015220.

13. Malat J et al. Soc Sci Med. 2018 Feb;199:148-56.

14. Kendi IX. How to be an antiracist. New York: Random House Books, 2019.

15. Gray DM 2nd et al. Nat Rev Gastroenterol Hepatol. 2020 Oct;17(10):589-90.

16. Vyas DA et al. N Engl J Med. 2020 Aug 27;383(9):874-82.

17. Green CR et al. J Natl Med Assoc. 2018 Feb;110(1):37-43.

18. Jones CP. Am J Public Health. 2000 Aug;90(8):1212-5.

19. Anyane-Yeboa A et al. Am J Gastroenterol. 2020 Aug;115(8):1147-9.

20. Issaka RB. JAMA. 2020 Aug 11;324(6):556-7.

21. Biden JR. Executive Order On Advancing Racial Equity and Support for Underserved Communities Through the Federal Government. Washington, D.C.: The White House, 2021.

On a busy call day, Oviea (a second-year gastroenterology fellow), paused in the hallway to listen to a conversation between an endoscopy nurse and a patient. The nurse was requesting the patient’s permission for a gastroenterology fellow to participate in their care and the patient, well acquainted with the role from prior procedures, immediately agreed. Oviea entered the patient’s room, introduced himself as “Dr. Akpotaire, the gastroenterology fellow,” as he had with hundreds of other patients during his fellowship, and completed the informed consent. The interaction was brief but pleasant. As Oviea was leaving the room, the patient asked: “When will I meet the doctor”?

This question was familiar to Oviea. Despite always introducing himself by title and wearing matching identification, many patients had dismissed his credentials since graduating from medical school. His answer was equally familiar: “I am a doctor, and Dr. X, the supervising physician, will meet you soon.” With the patient seemingly placated, Oviea delivered the consent form to the procedure room. Minutes later, he was surprised to learn that the patient specifically requested that he not be allowed to participate in their care. This in combination with the patient’s initial dismissal of Oviea’s credentials, left a sting. While none of the other team members outwardly questioned the reason for the patient’s change of heart, Oviea continued to wonder if the patient’s decision was because of his race.

Beyond gastroenterology, similar experiences are common in other spheres. The Twitter thread #BlackintheIvory recounts stories of microaggressions and structural racism in medicine and academia. The cumulative toll of these experiences leads to departures of Black physicians including Uché Blackstock, MD;¹ Aysha Khoury, MD, MPH;² Ben Danielson, MD;³ Princess Dennar, MD;⁴ and others.
 

Microaggressions as proxy for bias

The term microaggression was coined by Chester Pierce, MD, the first Black tenured professor at Massachusetts General Hospital in the 1970’s, to describe the frequent, yet subtle dismissals Black Americans experienced in society. Over time, the term has been expanded to include “brief and commonplace daily verbal, behavioral, or environmental indignities, intentional or unintentional, that communicate hostile, derogatory, or negative slights and insults” to any marginalized group.⁵

While the term microaggressions is useful in contextualizing individual experiences, it narrowly focuses on conscious or unconscious interpersonal prejudices. In medicine, this misdirects attention away from the policies and practices that create and reinforce prejudices; these policies and practices do so by systematically excluding underrepresented minority (URM) physicians,⁶ defined by the American Association of Medical Colleges as physicians who are Black, Hispanic, Native Americans, and Alaska Natives,⁷ from the medical workforce. Ultimately, this leads to and exacerbates poor health outcomes for racial and ethnic minority patients.

Microaggressions represent our society’s deepest and oldest biases and are rooted in structural racism, as well as misogyny, homophobia, transphobia, xenophobia, ableism, and other prejudices.⁸ For URM physicians, experiences like the example above are frequently caused by structural racism.
 

Structural racism in medicine

Structural racism refers to the policies, practices, cultural representations, and norms that reinforce inequities by providing privileges to White people at the disadvantage of non-White people.⁹ In 1910, Abraham Flexner, commissioned by the Carnegie Foundation and the American Medical Association, wrote that African American physicians should be trained in hygiene rather than surgery and should primarily serve as “sanitarians” whose purpose was to “protect Whites” from common diseases like tuberculosis.¹⁰ The 1910 Flexner Report also emphasized the importance of prerequisite basic sciences education and recommended that only two of the seven existing Black medical schools remain open because Flexner believed that only these schools had the potential to meet the new requirements for medical education.¹¹ A recent analysis found that, had the other five medical schools affiliated with historically Black colleges and universities remained open, this would have resulted in an additional 33,315 Black medical school graduates by 2019.¹² Structural racism explains why the majority of practicing physicians, medical educators, National Institutes of Health–funded researchers, and hospital executives are White and, similarly, why White patients are overrepresented in clinical trials, have better health outcomes, and live longer lives than several racial and ethnic minority groups.¹³

The murders of Ahmaud Arbery, Breonna Taylor, and George Floyd and the inequitable toll of the COVID-19 pandemic on Black, Hispanic, and Native American people renewed the dialogue regarding structural racism in America. Beyond criminal justice and police reform, the current social justice movement demands that structural racism is examined in all spheres. In medicine and health care, acknowledging the history of exclusion and exploitation of Black people and other URM groups is an important first step, but this must be followed by a commitment to an antiracist future for the benefit of all medical professionals and patients.^14,15

Antiracism as a path forward

Antiracism refers to actions and policies that seek to dismantle structural racism. While individuals can and should engage in antiracist actions, it is equally important for organizations and government to actively participate in this process as well.



Individual and interpersonal levels

Gastroenterologists should advocate an end to racist practices within their organizations (e.g., unjustified use of race-based corrections in diagnostic algorithms and practice guidelines),¹⁶ and interrupt microaggressions and racist actions in real time (e.g., overpolicing of underrepresented groups in health care settings).¹⁷ Gastroenterologists from underrepresented groups may also need to unlearn internalized racism, which is defined as acceptance by members of disadvantaged races of the negative messages about their own abilities and intrinsic worth.¹⁸



Organizational level

Gastroenterology divisions and practices must ensure that the entire workforce, including leadership, reflects the diversity of our country. Underrepresented groups represent 33% of the U.S. population, but only 9.1% of gastroenterology fellows and 10% of gastroenterology faculty are from underrepresented groups.¹⁹ In addition to diversifying the field of gastroenterology through financial and operational support of pipeline educational programs, organizations should also promote the scholarship of URM groups, whose work is often undervalued, and redistribute power by elevating voices that have been historically absent.²⁰ Gastroenterology practices should also collect high-quality patient data disaggregated by demographic factors. Doing so will enable rapid identification of disparate health outcomes by demographic variables and inform interventions to eliminate identified disparities.



Government level

The “Executive Order On Advancing Racial Equity and Support for Underserved Communities Through the Federal Government” issued by President Biden on Jan. 20, 2021, is an example of how government can promote antiracism.²¹ The executive order states that domestic policies cause group inequities and calls for the removal of systemic barriers in current and future domestic policies. The executive order outlines several additional ways to improve equity in current and future policy, including engagement, consultation, and coordination with members of underserved communities. The details outlined in the executive order should serve as the foundation for establishing new standards at the state, county, and city levels as well. Gastroenterologists can influence government by voting for officials at all levels that support and promote these standards.

Conclusion

Beyond calling out microaggressions in real time, we must also interrogate the biases, policies, and practices that support them in medicine and beyond. As Black gastroenterologists who have experienced microaggressions and overt acts of racism, we ground Oviea’s experience in structural racism and offer strategies that individuals, organizations, and governing institutions can adopt toward an antiracist future. This model can be applied to experiences rooted in misogyny, homophobia, transphobia, xenophobia, ableism, and other prejudices.

As a nation, we must make an active and collective choice to address structural racism. In health care, doing so will strengthen communities, enhance the lived experiences of URM physician colleagues, and save patient lives. Gastroenterologists, as trusted health care providers, are uniquely positioned to lead the way.

Dr. Akpotaire is a second-year GI fellow in the division of gastroenterology at the University of Washington, Seattle. Dr. Issaka is an assistant professor with both the Fred Hutchinson Cancer Research Center, Seattle, and the division of gastroenterology at the University of Washington.

References

1. Blackstock U. “Why Black doctors like me are leaving faculty positions in academic medical centers.” STAT News, 2020.

2. Asare JG. “One Doctor Shares Her Story of Racism in Medicine.” Forbes. 2021 Feb 1.

3. Kroman D. “Revered doctor steps down, accusing Seattle Children’s Hospital of racism.” Crosscut. 2020 Dec 31.

4. United States District Court Eastern District of Louisiana. Princess Dennar, M.D. v. The Administrators of the Tulane Educational Fund, 2020.

5. Sue DW. Microaggressions in Everyday Life: Race, Gender, and Sexual Orientation. Hoboken, N.J.: Wiley, 2010.

6. Boyd RW. Lancet. 2019 Jun 22;393(10190):2484-5.

7. AAMC. Diversity in Medicine Facts and Figures 2019. Washington, D.C., 2019.

8. Overland MK et al. PM R. 2019 Sep;11(9):1004-12.

9. Jones CP. Ethn Dis. 2018 Aug 9;28(Suppl 1):231-4.

10. Hlavinka E. “Racial Bias in Flexner Report Permeates Medical Education Today.” Medpage Today. 2020 Jun 18.

11. Flexner A. Medical Education in the United States and Canada. New York: 1910. Republished: Bull World Health Organ. 2002;80(7):594-602.

12. Campbell KM et al. JAMA Netw Open. 2020 Aug 3;3(8):e2015220.

13. Malat J et al. Soc Sci Med. 2018 Feb;199:148-56.

14. Kendi IX. How to be an antiracist. New York: Random House Books, 2019.

15. Gray DM 2nd et al. Nat Rev Gastroenterol Hepatol. 2020 Oct;17(10):589-90.

16. Vyas DA et al. N Engl J Med. 2020 Aug 27;383(9):874-82.

17. Green CR et al. J Natl Med Assoc. 2018 Feb;110(1):37-43.

18. Jones CP. Am J Public Health. 2000 Aug;90(8):1212-5.

19. Anyane-Yeboa A et al. Am J Gastroenterol. 2020 Aug;115(8):1147-9.

20. Issaka RB. JAMA. 2020 Aug 11;324(6):556-7.

21. Biden JR. Executive Order On Advancing Racial Equity and Support for Underserved Communities Through the Federal Government. Washington, D.C.: The White House, 2021.

On a busy call day, Oviea (a second-year gastroenterology fellow), paused in the hallway to listen to a conversation between an endoscopy nurse and a patient. The nurse was requesting the patient’s permission for a gastroenterology fellow to participate in their care and the patient, well acquainted with the role from prior procedures, immediately agreed. Oviea entered the patient’s room, introduced himself as “Dr. Akpotaire, the gastroenterology fellow,” as he had with hundreds of other patients during his fellowship, and completed the informed consent. The interaction was brief but pleasant. As Oviea was leaving the room, the patient asked: “When will I meet the doctor”?

This question was familiar to Oviea. Despite always introducing himself by title and wearing matching identification, many patients had dismissed his credentials since graduating from medical school. His answer was equally familiar: “I am a doctor, and Dr. X, the supervising physician, will meet you soon.” With the patient seemingly placated, Oviea delivered the consent form to the procedure room. Minutes later, he was surprised to learn that the patient specifically requested that he not be allowed to participate in their care. This in combination with the patient’s initial dismissal of Oviea’s credentials, left a sting. While none of the other team members outwardly questioned the reason for the patient’s change of heart, Oviea continued to wonder if the patient’s decision was because of his race.

Beyond gastroenterology, similar experiences are common in other spheres. The Twitter thread #BlackintheIvory recounts stories of microaggressions and structural racism in medicine and academia. The cumulative toll of these experiences leads to departures of Black physicians including Uché Blackstock, MD;¹ Aysha Khoury, MD, MPH;² Ben Danielson, MD;³ Princess Dennar, MD;⁴ and others.
 

Microaggressions as proxy for bias

The term microaggression was coined by Chester Pierce, MD, the first Black tenured professor at Massachusetts General Hospital in the 1970’s, to describe the frequent, yet subtle dismissals Black Americans experienced in society. Over time, the term has been expanded to include “brief and commonplace daily verbal, behavioral, or environmental indignities, intentional or unintentional, that communicate hostile, derogatory, or negative slights and insults” to any marginalized group.⁵

While the term microaggressions is useful in contextualizing individual experiences, it narrowly focuses on conscious or unconscious interpersonal prejudices. In medicine, this misdirects attention away from the policies and practices that create and reinforce prejudices; these policies and practices do so by systematically excluding underrepresented minority (URM) physicians,⁶ defined by the American Association of Medical Colleges as physicians who are Black, Hispanic, Native Americans, and Alaska Natives,⁷ from the medical workforce. Ultimately, this leads to and exacerbates poor health outcomes for racial and ethnic minority patients.

Microaggressions represent our society’s deepest and oldest biases and are rooted in structural racism, as well as misogyny, homophobia, transphobia, xenophobia, ableism, and other prejudices.⁸ For URM physicians, experiences like the example above are frequently caused by structural racism.
 

Structural racism in medicine

Structural racism refers to the policies, practices, cultural representations, and norms that reinforce inequities by providing privileges to White people at the disadvantage of non-White people.⁹ In 1910, Abraham Flexner, commissioned by the Carnegie Foundation and the American Medical Association, wrote that African American physicians should be trained in hygiene rather than surgery and should primarily serve as “sanitarians” whose purpose was to “protect Whites” from common diseases like tuberculosis.¹⁰ The 1910 Flexner Report also emphasized the importance of prerequisite basic sciences education and recommended that only two of the seven existing Black medical schools remain open because Flexner believed that only these schools had the potential to meet the new requirements for medical education.¹¹ A recent analysis found that, had the other five medical schools affiliated with historically Black colleges and universities remained open, this would have resulted in an additional 33,315 Black medical school graduates by 2019.¹² Structural racism explains why the majority of practicing physicians, medical educators, National Institutes of Health–funded researchers, and hospital executives are White and, similarly, why White patients are overrepresented in clinical trials, have better health outcomes, and live longer lives than several racial and ethnic minority groups.¹³

The murders of Ahmaud Arbery, Breonna Taylor, and George Floyd and the inequitable toll of the COVID-19 pandemic on Black, Hispanic, and Native American people renewed the dialogue regarding structural racism in America. Beyond criminal justice and police reform, the current social justice movement demands that structural racism is examined in all spheres. In medicine and health care, acknowledging the history of exclusion and exploitation of Black people and other URM groups is an important first step, but this must be followed by a commitment to an antiracist future for the benefit of all medical professionals and patients.^14,15

Antiracism as a path forward

Antiracism refers to actions and policies that seek to dismantle structural racism. While individuals can and should engage in antiracist actions, it is equally important for organizations and government to actively participate in this process as well.



Individual and interpersonal levels

Gastroenterologists should advocate an end to racist practices within their organizations (e.g., unjustified use of race-based corrections in diagnostic algorithms and practice guidelines),¹⁶ and interrupt microaggressions and racist actions in real time (e.g., overpolicing of underrepresented groups in health care settings).¹⁷ Gastroenterologists from underrepresented groups may also need to unlearn internalized racism, which is defined as acceptance by members of disadvantaged races of the negative messages about their own abilities and intrinsic worth.¹⁸



Organizational level

Gastroenterology divisions and practices must ensure that the entire workforce, including leadership, reflects the diversity of our country. Underrepresented groups represent 33% of the U.S. population, but only 9.1% of gastroenterology fellows and 10% of gastroenterology faculty are from underrepresented groups.¹⁹ In addition to diversifying the field of gastroenterology through financial and operational support of pipeline educational programs, organizations should also promote the scholarship of URM groups, whose work is often undervalued, and redistribute power by elevating voices that have been historically absent.²⁰ Gastroenterology practices should also collect high-quality patient data disaggregated by demographic factors. Doing so will enable rapid identification of disparate health outcomes by demographic variables and inform interventions to eliminate identified disparities.



Government level

The “Executive Order On Advancing Racial Equity and Support for Underserved Communities Through the Federal Government” issued by President Biden on Jan. 20, 2021, is an example of how government can promote antiracism.²¹ The executive order states that domestic policies cause group inequities and calls for the removal of systemic barriers in current and future domestic policies. The executive order outlines several additional ways to improve equity in current and future policy, including engagement, consultation, and coordination with members of underserved communities. The details outlined in the executive order should serve as the foundation for establishing new standards at the state, county, and city levels as well. Gastroenterologists can influence government by voting for officials at all levels that support and promote these standards.

Conclusion

Beyond calling out microaggressions in real time, we must also interrogate the biases, policies, and practices that support them in medicine and beyond. As Black gastroenterologists who have experienced microaggressions and overt acts of racism, we ground Oviea’s experience in structural racism and offer strategies that individuals, organizations, and governing institutions can adopt toward an antiracist future. This model can be applied to experiences rooted in misogyny, homophobia, transphobia, xenophobia, ableism, and other prejudices.

As a nation, we must make an active and collective choice to address structural racism. In health care, doing so will strengthen communities, enhance the lived experiences of URM physician colleagues, and save patient lives. Gastroenterologists, as trusted health care providers, are uniquely positioned to lead the way.

Dr. Akpotaire is a second-year GI fellow in the division of gastroenterology at the University of Washington, Seattle. Dr. Issaka is an assistant professor with both the Fred Hutchinson Cancer Research Center, Seattle, and the division of gastroenterology at the University of Washington.

References

1. Blackstock U. “Why Black doctors like me are leaving faculty positions in academic medical centers.” STAT News, 2020.

2. Asare JG. “One Doctor Shares Her Story of Racism in Medicine.” Forbes. 2021 Feb 1.

3. Kroman D. “Revered doctor steps down, accusing Seattle Children’s Hospital of racism.” Crosscut. 2020 Dec 31.

4. United States District Court Eastern District of Louisiana. Princess Dennar, M.D. v. The Administrators of the Tulane Educational Fund, 2020.

5. Sue DW. Microaggressions in Everyday Life: Race, Gender, and Sexual Orientation. Hoboken, N.J.: Wiley, 2010.

6. Boyd RW. Lancet. 2019 Jun 22;393(10190):2484-5.

7. AAMC. Diversity in Medicine Facts and Figures 2019. Washington, D.C., 2019.

8. Overland MK et al. PM R. 2019 Sep;11(9):1004-12.

9. Jones CP. Ethn Dis. 2018 Aug 9;28(Suppl 1):231-4.

10. Hlavinka E. “Racial Bias in Flexner Report Permeates Medical Education Today.” Medpage Today. 2020 Jun 18.

11. Flexner A. Medical Education in the United States and Canada. New York: 1910. Republished: Bull World Health Organ. 2002;80(7):594-602.

12. Campbell KM et al. JAMA Netw Open. 2020 Aug 3;3(8):e2015220.

13. Malat J et al. Soc Sci Med. 2018 Feb;199:148-56.

14. Kendi IX. How to be an antiracist. New York: Random House Books, 2019.

15. Gray DM 2nd et al. Nat Rev Gastroenterol Hepatol. 2020 Oct;17(10):589-90.

16. Vyas DA et al. N Engl J Med. 2020 Aug 27;383(9):874-82.

17. Green CR et al. J Natl Med Assoc. 2018 Feb;110(1):37-43.

18. Jones CP. Am J Public Health. 2000 Aug;90(8):1212-5.

19. Anyane-Yeboa A et al. Am J Gastroenterol. 2020 Aug;115(8):1147-9.

20. Issaka RB. JAMA. 2020 Aug 11;324(6):556-7.

21. Biden JR. Executive Order On Advancing Racial Equity and Support for Underserved Communities Through the Federal Government. Washington, D.C.: The White House, 2021.