Massachusetts ACP Meeting Update in Gastroenterology and Hepatology November 19th, 2016 Norton J. Greenberger, MD Senior Attending Physician Brigham and Women’s Hospital 1 Agenda • Stomach and Small Bowel – Thromboembolism and GI bleeding after anticoagulants D/C – Sprue- a common problem – Bariatric surgery • Colon – C. Difficile – Irritable Bowel Syndrome – Colonic Diverticular Diseases • Liver – Nonalcoholic Liver Diseas 2 The Risks of Thromboembolism Vs. Recurrent Gastrointestinal Bleeding After Interruption of Systemic Anticoagulation in Hospitalized Inpatients With Gastrointestinal Bleeding: A Prospective Study Sengupta N, et al, Am J Gastro 2015; 110: 328-335 3 Objective • Anticoagulants carry a significant risk of gastrointestinal bleeding (GIB) 4 Aim • To determine the safety and risk of continuation of anticoagulation after GIB 5 Methods • A prospective observational cohort study was conducted on patients admitted to the hospital who had GIB while on systemic anticoagulation. • Patients were classified into two groups at hospital discharge after GIB: those who resumed anticoagulation and those who had anti coagulation discontinued. 6 Results • 90 days after discharge the following outcomes were determined: – 197 patients who developed GIB while on systemic anticoagulation (n=145, 74% on warfarin) – During the follow-up period, 7 (4%) patients suffered a thrombotic event and 27 (14%) patients were readmitted for GIB – Anticoagulation continuation was independently associated on multivariate regression with a lower risk of major thrombotic episodes within 90 days. 7 Sengupta N, et al, Am J Gastro 2015; 110: p. 334 8 Conclusions • Restarting anticoagulation at discharge after GIB was associated with fewer thromboembolic events without a significantly increased risk of recurrent GIB at 90 days • The benefits of continuing anticoagulation at discharge may outweigh the risk of recurrent GIB. 9 Diagnosis of Celiac Sprue 1. Evidence of malabsorption (localized, generalized) 2. Abnormal small bowel biopsy (spectrum of changes) 3. Abnormal immunologic studies – 85-90% sensitivity 95% specificity • Anti-endomysial antibody • Tissue glutaminase antibody 4. Improvement with gluten-free diet (clinical, lab studies, histology) 5. Equivocal cases – gluten challenge 10