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123
A Curbside Guide
W. Harley Sobin
Kia Saeian
Patrick Sanvanson
Editors
Managing
Complex Cases in
Gastroenterology
Managing Complex Cases in Gastroenterology
W. Harley Sobin • Kia Saeian
Patrick Sanvanson
Editors
Managing Complex Cases in
Gastroenterology
A Curbside Guide
ISBN 978-3-031-48948-8 ISBN 978-3-031-48949-5 (eBook)
https://doi.org/10.1007/978-3-031-48949-5
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether
the whole or part of the material is concerned, specically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microlms or in any other physical way, and
transmission or information storage and retrieval, electronic adaptation, computer software, or by similar
or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply, even in the absence of a specic statement, that such names are exempt from the relevant
protective laws and regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, expressed or implied, with respect to the material contained herein or for any
errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional
claims in published maps and institutional afliations.
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Paper in this product is recyclable
Editors
W. Harley Sobin
Division of Gastroenterology and
Hepatology
Medical College of Wisconsin
Milwaukee, WI, USA
Patrick Sanvanson
Division of Gastroenterology and
Hepatology
Medical College of Wisconsin
Milwaukee, WI, USA
Kia Saeian
Division of Gastroenterology and
Hepatology
Medical College of Wisconsin
Milwaukee, WI, USA
v
Preface
This book was designed to help gastroenterologists take care of their patients with
challenging problems. Every day in practice we face patients with issues that are not
simple to master. Oftentimes, we search out some guidance from “the experts,” and,
if they are available, we will curbside them, either by phone or in person.
This text is written from the standpoint of a community gastroenterologist curb-
siding his academic cohorts with his challenging cases. We present a patient with a
difcult GI problem and ask the academic expert how he, or she, would manage the
case. We have provided over a hundred examples of problem cases and asked the
experts at the Medical College of Wisconsin (MCW) for help in their management.
These cases run the gamut, including general GI, motility disorders, inammatory
bowel disease, advanced therapeutics, hepatology, and disorders of gut–brain
interaction.
The main objective of this book is to compile the most clinically useful ques-
tions, present them to experts who frequently deal with these problems, and then
wrap up their knowledge within one clinically useful text. If a community gastroen-
terologist had endless access to an academic panel of GI experts, these are the ques-
tions they might ask. There are hundreds of useful clinical pearls between the pages
of this book which should help anyone taking care of patients with GI problems. We
want to thank the academic GI team at the Medical College of Wisconsin who, with
their hundreds of years of accumulated experience, share their invaluable counsel.
While the text may be targeted particularly toward practicing community gastro-
enterologists, it certainly can be of benet to GI fellows in training, academic gas-
troenterologists, and general internists and surgeons with a strong interest in
gastroenterology as well as APPs.
Of course, these opinions shouldn’t be accepted as the only choice for your
patient. Indeed, in some cases, we share several opinions for managing the same
condition. But any decision-making in your individual patient should be done in the
context of the latest developments, and specic medical details of your particular
patient. But we hope this text will serve as a useful adjunct in managing your more
difcult patients.
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vi
Disclaimer—the cases presented in this text are hypothetical composites and
don’t represent specic individuals.
We would like to acknowledge the substantial help of Pilar Kuderer and Clarissa
Marsh in the preparation of this text. They were assisted by Emma Kiefer and
Kari Warren.
W.HarleySobin
KiaSaeian
Milwaukee, WI PatrickSanvanson
Preface
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vii
Part I General GI
1 Introduction to the General GI Section . . . . . . . . . . . . . . . . . . . . . . . . . 3
W. Harley Sobin
2 Eosinophilic Esophagitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Patrick Sanvanson
3 Oropharyngeal Dysphagia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Patrick Sanvanson
4 Achalasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Benson Massey
5 Other Motility Disorders of the Esophagus and Achalasia . . . . . . . . . . 25
Francis Edeani
6 GERD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Patrick Sanvanson
7 Refractory GERD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
W. Harley Sobin
8 Surgery for GERD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Jon Gould
9 Barrett’s Esophagus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Kulwinder Dua and Wilfredo Pagani
10 PEG Tubes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
William Berger
11 Autoimmune Metaplastic Atrophic Gastritis . . . . . . . . . . . . . . . . . . . . . 65
Francis Edeani
12 Subepithelial Lesions and NETs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Phillip Chisholm
Contents
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viii
13 Viewpoints on Managing Common Clinical GI Disorders from
a Practitioner with Over 50 Years of “Real-World” Experience . . . . . 73
Helmut Ammon
14 Small Intestinal Bacterial Overgrowth . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Benson Massey
15 Unusual Causes of Abdominal Pain and Controversies
in Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
W. Harley Sobin and Patrick Sanvanson
16 Vascular Disorders of the Intestine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Jim Nelson
17 Polypectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Zachary Smith and Matt Mohorek
18 Rectal Incontinence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Ling Mei and Krupa Patel
19 Diverticulitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
William Berger, Keely Browning, and W. Harley Sobin
20 Pancreatic Cysts and Recurrent Pancreatitis . . . . . . . . . . . . . . . . . . . . . 139
Phillip Chisholm
21 Chronic Pancreatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Srivats Madhavan
22 GI Oncology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Ben George
23 Issues in Therapeutic Endoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Kulwinder Dua
24 GI Pharmacology: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
Elizabeth Pieper
Part II IBD Compendium
25 Introduction to the Inflammatory Bowel Disease Compendium . . . . . 181
W. Harley Sobin
26 Crohn’s Ileitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Preetika Sinh
27 Ulcerative Colitis Refractory to Mesalamine . . . . . . . . . . . . . . . . . . . . . 189
Daniel Stein and Salina Faidhalla
28 Managing Crohn’s in a Patient with Prior MI . . . . . . . . . . . . . . . . . . . . 193
Preetika Sinh
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29 Managing Post-Op Crohn’s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
Amir Patel
30 Managing Pseudopolyps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
Poonam Beniwal-Patel
31 Ulcerative Colitis Refractory to Anti-TNF . . . . . . . . . . . . . . . . . . . . . . . 201
Daniel Stein and Salina Faidhalla
32 Acute Severe Ulcerative Colitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Amir Patel
33 Resistant/Refractory Proctitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
Poonam Beniwal-Patel
34 Vaccinations in Newly Diagnosed IBD . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Preetika Sinh
35 Ustekinumab vs Risankizumab in Crohn’s . . . . . . . . . . . . . . . . . . . . . . 211
Daniel Stein and Salina Faidhalla
36 Use of Vedolizumab in UC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
Daniel Stein and Salina Faidhalla
37 Functional Diarrhea in IBD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
Amir Patel
38 When to Postpone Infusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
Poonam Beniwal-Patel
39 Musculoskeletal Complaints in a Patient on Anti-TNFs . . . . . . . . . . . . 223
Amir Patel
40 Use of Immune Modulators in Patients Being Started
on Anti-TNFs
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
Daniel Stein and Salina Faidhalla
41 Pyoderma Gangrenosum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
Poonam Beniwal-Patel
42 UC in a Patient Who Failed Mesalamine and Anti-TNF . . . . . . . . . . . . 229
Daniel Stein and Salina Faidhalla
43 Patients with IBD Who Are Squeamish About Rectal Meds
and Self-Injection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
Amir Patel
44 Colon Stricture in UC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
Poonam Beniwal-Patel
45 Nonspecific Ileal Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
Amir Patel
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46 Concern About Pneumocystis jirovecii . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
Poonam Beniwal-Patel
47 Bloating in Crohn’s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
Poonam Beniwal-Patel
48 Severe Diarrhea in a Patient on Chemotherapy . . . . . . . . . . . . . . . . . . . 241
Amir Patel
49 Microscopic Colitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
Poonam Beniwal-Patel
50 Miscellaneous Questions About IBD . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
Daniel Stein, Salina Faidhalla, and Amir Patel
Part III Disorders of Gut–Brain Interaction
51 Introduction to Disorders of Gut-Brain Interaction . . . . . . . . . . . . . . . 253
W. Harley Sobin
52 IBS-D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
W. Harley Sobin and Patrick Sanvanson
53 IBS-C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
W. Harley Sobin and Patrick Sanvanson
54 Functional Dyspepsia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
W. Harley Sobin and Patrick Sanvanson
55 Bloating . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
W. Harley Sobin and Patrick Sanvanson
Part IV Hepatology Compendium
56 Introduction to the Hepatology Compendium . . . . . . . . . . . . . . . . . . . . 281
W. Harley Sobin
57 Liver Enzyme Elevation-negative Work-up . . . . . . . . . . . . . . . . . . . . . . 285
Francisco Durazo
58 Increased LFTs with Increased Iron . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
Jose Franco
59 Increased LFTs with Low Ceruloplasmin . . . . . . . . . . . . . . . . . . . . . . . 291
Jose Franco
60 Normal Ceruloplasmin-Suspected Wilson’s . . . . . . . . . . . . . . . . . . . . . . 293
Jose Franco
61 Increased LFTs-Alpha 1 Antitrypsin Deficiency . . . . . . . . . . . . . . . . . . 295
Jose Franco
Contents
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