BACKGROUND:Sleeve gastrectomy (SG) is the most commonly performed bariatric procedure in the United States, but it is associated with an increased risk of de novo or worsened gastroesophageal reflux disease (GERD). Conversion to Roux-en-Y gastric bypass (RYGB) is considered the gold standard for treating refractory GERD after SG, though objective outcomes remain under-reported. OBJECTIVES:To evaluate the efficacy of conversion from SG to RYGB for medically refractory GERD using objective measures of improvement. Secondary objectives included assessing whether weight loss, additional anatomic repairs, or application of updated American College of Gastroenterology (ACG) GERD diagnostic criteria impacted outcomes. SETTING:Academic tertiary care center (Cleveland Clinic Foundation, Cleveland, Ohio, United States). METHODS:A retrospective cohort study was conducted on patients who underwent SG followed by RYGB for refractory GERD from July 2004 to August 2024. GERD improvement was defined as decreased use of proton pump inhibitors (PPIs), endoscopic, or pH testing improvement. Logistic regression and chi-square analyses were used to assess predictors of improvement. RESULTS:Of 117 patients, 53 (45.3%) showed objective GERD improvement post-RYGB. Most improved via reduction in PPI omeprazole equivalence (88.7%), of which 35.8% discontinued PPIs completely. Neither total body weight loss (P = .257) nor concurrent anatomical repairs (P = .615) correlated with GERD improvement. Meeting new ACG GERD diagnostic criteria was significantly associated with improvement (63.6% vs 33.3%, P = .03). CONCLUSION:Conversion to RYGB results in objective GERD improvement in nearly half of patients undergoing conversion, independent of weight loss or anatomical repairs. ACG diagnostic criteria may help predict which patients benefit most. Prospective studies are needed to validate findings and refine surgical decision-making.

Dupilumab is increasingly used for the treatment of eosinophilic esophagitis (EoE), yet its infectious safety profile in real-world clinical practice remains incompletely defined. Given the immunomodulatory effects of IL-4/IL-13 pathway inhibition, understanding infection risk relative to conventional therapies, such as proton pump inhibitors (PPIs) and swallowed TCS, is clinically important. Using the TriNetX Research USA network, we conducted three retrospective propensity-matched cohort analyses among adults with EoE initiating (1) dupilumab vs. PPIs, (2) dupilumab vs. topical steroids, (3) dupilumab vs. combined PPI/topical steroid therapy, and (4) dupilumab vs. no treatment. Patients receiving other systemic immunosuppressive biologics were excluded. One-to-one matching was adjusted for demographics and comorbidities associated with infection risk. Infectious outcomes ≥ 30 days post-index were noted. Relative risks and Kaplan–Meier analyses were performed. After propensity matching, cohorts included 3053 pairs (dupilumab v. PPI), 2143 pairs (dupilumab v. topical steroids), 3973 pairs (dupilumab v. combined therapy), and 2329 pairs (dupilumab vs. no treatment). Infection rates were similar between dupilumab and PPIs or topical steroids alone across all outcomes. Compared with combined PPI/topical steroid therapy, dupilumab was associated with lower rates of COVID-19 (10.3 vs. 12.6

Choledocholithiasis (CDL) is a common indication for endoscopic retrograde cholangiopancreatography (ERCP). While guidelines use static hepatic biomarker values to estimate pre-test probability, the utility of trending these labs (bilirubin and alkaline phosphatase [ALP]) is unclear. It is unknown if improving biomarker trends reliably indicate stone passage and can help avoid unnecessary procedures. To evaluate whether serial trends in hepatic biomarkers prior to ERCP can predict the presence of suspected CDL in hospitalized patients and guide decisions on ERCP referral. We conducted a retrospective study of 198 patients undergoing ERCP for suspected CDL from 2002 to 2018. Patients were categorized based on biomarker trends, primarily into: Group 1 (normalized bilirubin with normalized ALP or ALP falling ≥ 50

Introduction:The global prevalence of obesity is rising, paralleled by an increase in IBD (inflammatory bowel disease). While studies examining the impact of obesity on IBD have yielded conflicting results, some suggest that obesity may increase adverse outcomes, whereas BS (bariatric surgery) has been associated with improved IBD outcomes in patients with obesity. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have emerged as a less invasive alternative to BS for managing obesity, with recent studies indicating potential benefits for IBD outcomes. However, GLP-1 RAs have not been directly compared with BS in patients with obesity and IBD. Methods:We conducted a retrospective cohort analysis using TriNetX, a database aggregating data from over 200 healthcare organizations across the United States. Adult patients with IBD were identified using ICD-10 codes. The cohort was divided into two groups: patients with obesity and IBD prescribed GLP-1 RAs (dulaglutide, semaglutide, liraglutide, lixisenatide, exenatide, albiglutide, or tirzepatide) who had not undergone BS, and patients with obesity and IBD who underwent BS but had not received GLP-1 RAs. To ensure active exposure, GLP-1 RA use required at least two prescriptions separated by at least 1 month. Propensity score matching was performed based on demographics, comorbidities, and IBD medications. Categorical variables were compared using chi-square tests, and continuous variables were compared using independent t-tests. Effect estimates were reported as odds ratios (ORs) with 95% confidence intervals (CIs), with statistical significance defined as P < .05. Results:A total of 17142 patients with obesity and IBD were identified, including 12965 patients treated with GLP-1 RAs and 4177 patients who underwent BS. Patients in the GLP-1 RA group were older at index (56.7 vs 52.9 years). They also had higher rates of comorbidities, including diabetes (64.3% vs 31.5%), chronic kidney disease (19.6% vs 14.1%), and nicotine dependence (20.4% vs 19.1%), but lower rates of alcohol use disorder (2.3% vs 4.6%), compared with the BS group. The GLP-1 RA group also had higher baseline use of IBD-related medications, including corticosteroids, immunomodulators, and biologic therapies. After propensity score matching, 3478 patients were included in each cohort. Despite a higher post-intervention BMI (body mass index) (34.5 vs 33.4 kg/m2; P < .0001) and shorter follow-up, patients treated with GLP-1 RAs demonstrated significantly lower odds of lower extremity deep venous thrombosis (OR 0.24, 95% CI, 0.16-0.35), pulmonary embolism (OR 0.27, 95% CI, 0.17-0.41), Clostridioides difficile infection (OR 0.22, 95% CI, 0.14-0.34), intestinal obstruction (OR 0.21, 95% CI, 0.15-0.29), abdominal pain (OR 0.34, 95% CI, 0.28-0.42), nausea (OR 0.42, 95% CI, 0.35-0.50), constipation (OR 0.44, 95% CI, 0.37-0.53), colectomy (OR 0.13, 95% CI, 0.09-0.20), and IBD flares (OR 0.44, 95% CI, 0.37-0.54), all P < .0001, compared with BS. Initiation of advanced IBD therapies was also lower in the GLP-1 RA group (OR 0.45, 95% CI, 0.33-0.61; P < .0001). Conclusion:Despite a higher burden of comorbidities and a greater mean BMI, patients with obesity and IBD treated with GLP-1 RAs experienced significantly fewer gastrointestinal complications, thromboembolic events, disease flares, and surgical interventions compared with those undergoing BS. These findings suggest that GLP-1 RAs may represent a viable, less invasive therapeutic option for weight management and disease modulation in patients with obesity and IBD.

Importance:Glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) are known to increase the risk of retained gastric contents. High-quality data are lacking to guide periprocedure management of GLP-1 and GIP agonists. Objective:To compare the risk of clinically significant residual gastric volume (RGV) in patients who continue vs hold 1 dose of weekly or daily GLP-1 and GIP agonists prior to sedation. Design, Setting, and Participants:This randomized, single-masked clinical trial conducted at 2 large tertiary referral centers in the US included patients undergoing elective upper endoscopy (EGD) who were receiving GLP-1 or GLP-1/GIP agonists between July 2024 and May 2025. Eligible participants were adults aged 18 years or older, scheduled for EGD with or without colonoscopy, under moderate sedation or monitored anesthesia care, and taking a stable dose of a GLP-1 or GLP-1/GIP agonist for at least 1 month. Exclusion criteria were prior foregut surgery, achalasia, documented gastroparesis, RGV on previous endoscopy, gastric outlet obstruction, planned general anesthesia, or recent opioid use. Data were analyzed May 2025. Intervention:Participants were randomized to either continue their medication or hold 1 dose prior to the procedure. Main Outcomes and Measures:Clinically significant RGV, a composite of gastric contents that (1) precludes endoscopic examination, (2) requires premature termination or endotracheal intubation, and/or (3) results in an aspiration event that necessitates extended observation or monitoring, unplanned therapeutics, or hospital admission. Results:There were 60 patients (32 holding 1 dose, 28 continuing medication) in the preplanned interim analysis (median [IQR] age, 62.5 [55.5-67.5] years; 30 female [50.0%]). Clinically significant RGV occurred in 3.1% in the hold group vs 25.0% in the continue group (absolute difference, 21.9% [90% CI, 7.0%-36.7%]; P = .003). The trial was terminated early as risk exceeded the preestablished O'Brien-Fleming stopping boundary. In the EGD-only subgroup (35 patients), clinically significant RGV occurred in 46.7% in the continue vs 5.0% in the hold groups (absolute difference, 41.7% [90% CI, 17.9%-65.4%]; P = .001). In the EGD plus colonoscopy subgroup (25 patients), who were on clear liquids the day prior, no patients had clinically significant RGV. Conclusions and Relevance:This randomized clinical trial found that continuing GLP-1 or GIP agonist in the preprocedural period increased clinically significant RGV but did not increase the risk of other adverse events. Clear liquids the day prior to the procedure may mitigate the risk of clinically significant RGV regardless of GLP-1/GIP use. Trial Registration:ClinicalTrials.gov Identifier: NCT06533527.

BACKGROUND:Early enteral nutrition (EEN) is preferred for severe acute pancreatitis (SAP) patients, but the optimal timing is controversial. The clinical implications of initiating EEN within 48 hours versus later (>48 h) in predicted SAP patients are unclear. This study compares outcomes in predicted SAP patients receiving EEN within 48 hours to those receiving it later. METHODS:Retrospective cohort study of adults (18 years or older) with predicted SAP (BISAP score ≥2) from May 2011 to July 2023. EEN was defined as initiation within 48 hours of diagnosis. Exclusions included inaccurate diagnoses, outside transfers, missing data, chronic pancreatitis, acute exacerbations of chronic pancreatitis, and TPN-only treatment. Statistical analysis included χ 2 , Fisher exact tests, and 2-sample t -tests. RESULTS:Among 83 predicted SAP patients, 27 received EEN within 48 hours, and 56 received late feeding. Baseline characteristics, including age, gender, BMI, and BISAP score, were similar. Postpyloric feeding was used in 91.6%, and 45.6% reached goal feeding rates in <72 hours. The EEN group had statistically significant shorter ICU stays (14.7 vs. 25.4 d, P =0.011), fewer pancreatic fluid collections (22.2% vs. 48.2%, P =0.043), and fewer gastrointestinal complications (48.1% vs. 75%, P =0.03). Early EEN (<48 h) showed improved composite outcomes, including decreased mortality, ICU needs, early systemic complications, and lower hospital and ICU costs. CONCLUSION:This novel study demonstrated that initiating EEN within 48 hours in predicted SAP patients significantly improves outcomes, highlighting its importance in management. These findings support EEN as a clinical standard for SAP patients and call for future prospective studies to confirm its benefits.

INTRODUCTION:Gastroparesis (GP) is a well-recognized complication in patients with long-standing type 2 diabetes (T2D), impacting glycemic control and continuous glucose monitoring (CGM) metrics. We performed a prospective study to characterize real-time glucose metrics in patients with T2D with gastroparesis. METHODS:This pilot prospective study involved 11 adult patients with T2D and GP (GP group) and 20 patients with T2D without GP (non-GP group). Patients used real-time CGM (rtCGM) FreeStyle Libre 3 throughout the 4-week study. Fifteen glycemic metrics, including time in range (TIR), time above range (TAR), and time below range (TBR), were analyzed from the rtCGM profiles of study participants. RESULTS:Compared with the non-GP group, patients in the GP group had higher mean CGM glucose levels (GP group [172 ± 51 mg/dL] vs. non-GP group [157 ± 41 mg/dL]) and lower TIR, indicating inadequate glucose control. The GP group also had greater TAR, increased TBR, and higher standard deviation (SD) and coefficient of variation (CV), indicating greater glucose excursions and glucose variability. CONCLUSION:Patients with T2D and GP showed distinct and altered CGM glucose metrics compared with those with T2D without GP. These findings highlight the need for better glycemic control in this population. Whether CGM metrics could help identify a specific biomarker for gastroparesis remains to be determined. Further validation with a broader population, including patients with T1D and GLP-1RAs, is necessary.

To reverse fibrosis in late-stage metabolic dysfunction-associated steatohepatitis (MASH), guidelines recommend that patients shed at least 10% of their body weight. However, losing this much weight remains a challenge for most patients, especially with lifestyle modifications alone. Moreover, not all patients with MASH are overweight or obese. This review summarizes pharmacologic, surgical, and bariatric endoscopic treatments for MASH to guide primary care physicians and internists.

Background and aims Gastrointestinal (GI) histiocytosis is an uncommon and heterogeneous finding that may represent reactive, infectious, medication-related, or neoplastic processes. Because lesions are often identified incidentally on biopsy, their true frequency, etiologic spectrum, and optimal diagnostic approach remain poorly defined. We aimed to characterize GI histiocytosis using a large institutional cohort and contextualize findings using a review of published adult cases. Methods We performed a retrospective case series of adult patients at the Cleveland Clinic Foundation with histiocytic involvement of the GI tract identified on pathology specimens between 2007 and 2022, along with a systematic review of adult cases published on PubMed from 2002 to 2022. Extracted data included demographics, presenting symptoms, indications for endoscopy, anatomic distribution, endoscopic findings, associated conditions, and available immunohistochemical and molecular results. Results The institutional cohort included 108 patients (mean age 63.7 years; 60.2% female), of whom 35% were asymptomatic. Involvement spanned the esophagus to rectum, most commonly affecting the stomach. Endoscopic findings ranged from normal mucosa to polyps, nodules, and ulcerations. Nearly half of cases lacked definitive etiologic classification. Conclusions GI histiocytosis may be more common than previously appreciated but frequently remains incompletely evaluated in routine clinical practice. Integrating clinical context with targeted histologic assessment and selective molecular testing may help distinguish incidental reactive findings from clinically significant histiocytic disorders.