Gastrointestinal Disorders

Nausea & Vomiting

A 2020 AGA meta-analysis reported a pooled prevalence of nausea or vomiting (usually mild) in 7.8% of patients with acute COVID-19.

Up to 16% of patients may present with gastrointestinal symptoms (anorexia, nausea, diarrhea) in the absence of respiratory symptoms.

Acute Upper Gastrointestinal Bleeding

Compared with surgical intervention for recurrent or refractory bleeding, embolization achieves equivalent clinical success rates with lower mortality.

Occult Gastrointestinal Bleeding

A 2020 AGA guidelines recommends an initial trial of empiric iron therapy for patients with iron deficiency anemia who have no significant findings on upper endoscopy or colonoscopy and who are without symptoms of small intestinal disease.

A sustained rise in ferritin and hemoglobin with 1–2 months of iron therapy may obviate the need for further studies.

Further investigation of the small intestine is recommended in patients who have anemia that responds poorly to empiric iron supplementation, who have signs of ongoing bleeding (fecal occult blood) or who have worrisome symptoms (abdominal pain, weight loss).

Capsule endoscopy is recommended as the initial study in most patients to look for vascular ectasias and to exclude a small intestinal neoplasia or inflammatory bowel disease.

Achalasia

Pneumatic dilation, Heller cardiomyotomy, and POEM provide comparable short- and long-term symptomatic improvement in achalasia types I or II.

For type III (spastic) achalasia, POEM with a long distal myotomy may be preferred to Heller cardiomyotomy where expertise is available.

Ulcerative Colitis

For patients who require more than one course of corticosteroid therapy every 1–2 years for symptomatic relapse, treatment should be ‘stepped up’ to include a thiopurine (azathioprine or mercaptopurine) or a biologic agent.

A 2020 AGA guideline recommends either infliximab or vedolizumab as first-line therapies for moderate to severe colitis based on their efficacy and safety profiles.

These two agents had the highest rankings of all biologic agents for induction of clinical remission in a 2020 network meta-analysis.

Although infliximab may be the more effective agent (especially for severe disease), vedolizumab may be the preferred first-line therapy in patients who are elderly or have increased medical comorbidities due to its significantly lower incidence of infectious complications.

Nonfamilial Adenomatous & Serrated Polyps

The US Multi-Society Task Force Guideline provide the following recommendations for repeat colonoscopy that depend on the findings at baseline colonoscopy:

• – 10 years: normal colonoscopy or fewer than 20 hyperplastic polyps < 10 mm in the distal colon or rectum

• – 7-10 years: 1–2 adenomas < 10 mm

• – 5-10 years: 1–2 sessile serrated polyps < 10 mm

• – 3-5 years: 3–4 adenomas or sessile serrated polyps < 10 ...