When patients have an autoimmune liver disease, their immune cells attack one of their liver’s two main types of cells: hepatocytes and cholangiocytes. Hepatocytes perform most of the liver’s metabolic functions, while cholangiocytes modify and move bile from the liver to the small intestine.  

The primary autoimmune disease that targets the hepatocytes is called autoimmune hepatitis (AIH). The diseases that strikes the cholangiocytes are primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC).  

AIH is more common among the three; PSC, though rare, occurs more commonly among patients with inflammatory bowel disease such as Crohn’s disease and ulcerative colitis. Some patients have features of two diseases at the same time, such as presenting with both AIH and PBC, or both AIH and PSC.  

“In many patients, the immune cells don’t discriminate, and they attack both types of cells,” says Lily Dara, MD, a hepatologist with the �������� Liver Health Center, part of the �������� Digestive Health Institute and ��������. She specializes in the clinical treatment and research of rare and complex liver diseases, including autoimmune liver diseases. 

What causes the immune system to work against the liver is, unfortunately, unclear. “We don’t fully understand why some people get autoimmune liver disease, although there are certain genes that seem to predispose patients to autoimmunity,” Dara says, adding that there does seem to be a genetic association with AIH. 

How autoimmune liver diseases (AIH, PBC and PSC) can impact the liver 

In these diseases, immune cells attack and destroy the liver cells, resulting in chronic inflammation. If uncontrolled, the inflammation can lead to fibrosis — which in turn can progress to chronic liver disease, cirrhosis, cancer, liver failure and the need for a liver transplant. 

“It’s very important to diagnose and treat these chronic autoimmune liver diseases in a timely manner so the patient does not develop chronic liver disease,” says Dara, who treats patients at Keck Hospital of ��������, �������� Norris Cancer Hospital and ��������’s new Pasadena location at 590 S. Fair Oaks Ave. 

Diagnosing autoimmune liver diseases  

Often, people who have undiagnosed AIH or PBC experience nonspecific symptoms such as fatigue and itching. While roughly 20% to 25% of people with AIH present with an acute flare — involving nausea or abdominal pain, very elevated liver enzymes and even jaundice — the symptoms can be silent in most people with AIH. Strikingly, in AIH, for example, roughly one out of three patients, or 30%, are diagnosed when they are already cirrhotic. 

To help diagnose AIH, PBC and PSC, primary care physicians should pay attention to their patients’ liver enzyme levels — specifically, aspartate aminotransferase (AST), alanine aminotransferase (ALT) and alkaline phosphatase (ALP). 

“On annual labs, physicians should be on the lookout for abnormal liver enzyme results,” Dara advises. “More often than not, it’s the primary care physician who picks up on the disease with abnormal AST-ALT or ALP results.” 

Sadly, many people’s elevated liver enzymes get ignored, even when they’re in the early stages of autoimmune liver disease. “Sometimes the abnormalities in the lab results are subtle,” Dara says. “However, abnormalities in AST-ALT and ALP, even if minor, should be taken seriously.” 

When it comes to PBC, a test that identifies the presence of the antimitochondrial M2 antibody (AMA-M2) generally confirms the diagnosis. This antibody is present in about 85% to 90% of patients with this disease. If the AMA antibody is not present, but the suspicion for abnormality is high, special tests and often a liver biopsy are performed. 

Because the diagnosis of AIH is more complicated, a liver biopsy is usually always required to confirm it. “It is very important to make sure the diagnosis is accurate before we put someone on high-dose, lifelong immunosuppression,” Dara says. 

PSC is strongly associated with inflammatory bowel disease (IBD), but it is a rare disease that can manifest even in the absence of colitis. It is typically diagnosed by a special type of MRI called magnetic resonance cholangiopancreatography (MRCP) in patients who have elevated ALP enzymes. Although rarely, some patients may need a liver biopsy. These patients can be asymptomatic or present with fatigue, itching, jaundice and infection. The MRI shows a specific pattern called “beading” of the bile ducts, and this confirms the diagnosis.  

“The concern for PSC is that it significantly increases the lifetime risk of bile duct and liver cancer,” Dara says. “This places a huge psychological burden on the patients on top of their symptoms.” 

Gender and other risk factors for autoimmune liver disease 

Autoimmune liver diseases are more common in women, but that reality isn’t specific to the liver. “AIH and PBC tend to occur more in women,” Dara says. The reason for the gender imbalance is unknown, though it may be related to hormones, she notes. 

That said, PSC, which typically involves the large bile ducts, is more common in men than women. “Just because these diseases are rare in men doesn’t mean men don’t get them,” Dara points out. 

Autoimmune liver diseases affect all ethnicities and races. These diseases also can happen at any age, with one caveat: unlike AIH and PSC, PBC doesn’t appear to occur in children. 

Aside from gender, having other autoimmune disorders — such as hypothyroidism, lupus, rheumatoid arthritis, etc. — is also a risk factor for developing autoimmune liver disease. With PSC, it’s very common to also have inflammatory bowel disease. 

Treating AIH and PBC 

For PBC, the first line of treatment is ursodeoxycholic acid (UDCA), which brings down ALP levels and inflammation, and has been clearly shown to improve patient survival. Still, about 40% of patients with PBC do not fully respond to UDCA. For these individuals, two newly FDA-approved medications, elafibranor and seladelpar, can bring down their ALP levels even further. 

For AIH, the treatment is more limited: patients receive steroids along with some steroid-sparing immunosuppressive agents. “There’s been a lot of push from the hepatology community to get more research to find better steroid-sparing agents for people suffering from AIH,” Dara says. 

PSC remains one of the most difficult diseases to treat as there are no known disease-modifying treatments. The PSC community, however, has been very influential in lobbying for therapies, and the good news is there seems to be some momentum and a number of drugs and clinical trials in development.  

Providing multidisciplinary care 

Last year, Keck Medicine opened its newest Pasadena location at 590 S. Fair Oaks Ave., where specialists treat a wide range of conditions, including autoimmune liver disease. Dara says this autoimmune liver clinic focuses on a multidisciplinary, collaborative approach involving specialists focused on immune disorders in various organs and their overlapping conditions. These include hepatology, gastroenterology — specifically for IBD like ulcerative colitis and Crohn’s disease — rheumatology, neurology, dermatology and allergies.  

“When you have a rare disease, you really want to see a rare-disease specialist. And a lot of our patients have multiple autoimmune disorders, so coordinating their care and being on the same page about their immunosuppression is very important,” she concludes. 

The post Which Are the 3 Most Commonly Underdiagnosed Autoimmune Liver Diseases?�� appeared first on ��������.

The premise that GLP-1 receptor agonists are replacing bariatric surgery for weight management is not just oversimplified; it’s wrong.  

What these medications have actually done is forced a long-overdue shift in how obesity care is approached. The old model — diet and exercise, then maybe medication, then surgery as a last resort — is being replaced by something far more aligned with the biology of the disease: multimodal, individualized and long-term treatment. 

“People think this is a question of medication versus surgery,” says Harry J. Wong, MD, MS, a bariatric surgeon and obesity medicine specialist who focuses on gastrointestinal conditions with �������� Surgery and the �������� Digestive Health Institute, part of ��������. “That’s not how we practice anymore. We use all the tools in our toolbox.” 

Oral GLP-1s are poised to expand obesity treatment even further by providing another route for patients who cannot or do not want to use injections. More than in the United States filled a prescription for oral semaglutide in just the first six weeks after the pill was approved by the Food and Drug Administration (FDA) in December 2025.  

While this new tool is certainly exciting for practitioners treating obesity, Wong cautions nuance.  

“People hear ‘pill’ and think it’s simpler,” he says. “But the semaglutide (Wegovy) pill actually has to be taken in a very specific way.” Daily dosing, strict fasting requirements and absorption variability make oral formulations less straightforward than they appear. But having more options to treat obesity is never a bad thing, he says.  

“This is just another tool, and for some patients — especially those who can’t or won’t inject — it’s a great option,” he adds. 

More recently, , a small-molecule (nonpeptide) oral GLP-1 receptor agonist that can be taken once daily without fasting or water restrictions, addressing one of the key adherence challenges of earlier oral formulations. “For patients who struggled with the strict dosing requirements of oral semaglutide, this represents a meaningful step forward in real-world usability,” Wong says. “That said, oral agents as a class still produce somewhat less weight loss than their injectable counterparts, which is why patient selection and shared decision-making remain central to good obesity care.” 

The real impact of GLP-1s: Patients are finally showing up  

If GLP-1s have disrupted anything, it’s patient behavior. For decades, bariatric surgery has been dramatically underutilized. Less than 1% of eligible patients ever undergo surgery. Meanwhile, in just a few years, GLP-1 medications have reached a staggering portion of the population. 

“Now you have one in eight Americans who’ve tried a GLP-1,” Wong says. “If anything, the popularity of GLP-1s has helped patients realize they can actually get treatment for their obesity.” 

And that shift matters. Many patients who would never have considered surgery are now entering the health care system seeking help with weight management and weight-related comorbidities. As the stigma around weight management and obesity lessens — though it is still present — more patients are recognizing that obesity is a complex, chronic condition and needs to be treated as such, rather than a personal moral failing. For physicians, this represents an opportunity, not a threat. 

While hybrid treatment is great, surgery is still essential for some patients 

At multidisciplinary obesity treatment centers like the �������� Digestive Health Institute’s, medications are already being used in a multidisciplinary fashion. They are being used before surgery to help reduce complications and make surgery safer. In some cases, they can take the place of surgery. And after surgery, they can be used to help further optimize weight loss, reduce “food noise”, and prevent weight gain recurrence in the long-term. 

“We use GLP-1s to optimize patients before surgery,” Wong explains. “If someone has a very high BMI, preoperative weight loss reduces operative risk and improves outcomes.” 

Although GLP-1s are effective, they do have limits. “You’re looking at roughly 10% to 20% total body weight loss on average with the current GLP-1 medications,” Wong says. “For a patient starting at a BMI of 60, that’s clinically meaningful progress, but it may not get them to a healthy range.” For those patients, surgery remains essential. That’s why obesity care requires multiple options for treatment.  

“If you’re a hammer, everything looks like a nail. And it’s the same with obesity treatment. If you only know how to do one thing, that’s all you will ever do,” Wong says. “But patients are different. Their goals are different.” That’s why discussion of these new therapies and how they work for patients is so important. If patients have only ever been told that the only way to lose weight is with diet and exercise, that’s all they will ever try.  

“I still have patients who are told, ‘You don’t need medication. You don’t need surgery. Just do it yourself,’” Wong says. But that advice ignores the underlying physiology of obesity. 

“You’re fighting against your body,” he says. “And when you’re fighting physiology with willpower, physiology almost always wins.” 

Until that mindset shifts — among both patients and providers — many individuals will continue to go untreated. Increasingly, however, conversations happening around peoples’ successes with GLP-1s will bring more patients into their doctors’ offices.  

“Learning about these new tools puts us in a better place to counsel patients,” Wong says. “This isn’t about picking one treatment. It’s about using the right combination for the right patient.” 

The post GLP-1s Are Not the End of Bariatric Surgery; They’re the Beginning of Better Obesity Care�� appeared first on ��������.

Breakthrough treatments for gastrointestinal cancers are being tested in clinical trials right now. For many patients, these trials are an invaluable opportunity to access novel therapies. Clinical trials offer cutting-edge opportunities for patients throughout their entire journey, including early in their disease course. This is why a consultation about potential trial options should occur before any treatment starts.

More patients and physicians need to be made aware of this early on so that it factors into their treatment decisions, says Syma Iqbal, MD, a gastrointestinal oncologist with the �������� Norris Comprehensive Cancer Center, part of ��������, who sees patients at �������� Norris Cancer Hospital, Keck Hospital of �������� and Keck Medicine’s newest Pasadena location at 590 S. Fair Oaks Ave.

As section chief of gastrointestinal oncology for the Keck School of Medicine of ��������, Iqbal is a leader in clinical research on gastrointestinal malignancies. Ahead, she shares insights and recommendations based on her firsthand experience.

Before we get into clinical trials specifically, what are some of the most exciting advances happening in GI cancer treatment?

We are in an era of gastrointestinal oncology where treatment is not one-size-fits-all. Through molecular profiling, we’re able to study the profile of a patient’s tumor and determine which targeted therapy is going to enable the best outcome.

Here are a few examples: For esophagogastric cancers, in addition to chemotherapy we’ve now expanded our armamentarium to include agents that target PD-L1, HER2, deficiency of mismatch repair genes, CLDN 18.2 as well as other novel targets. The development of new immunotherapy agents, targeted antibodies as well as novel combinations of immunotherapy agents has allowed for new studies in patients with advanced or metastatic disease as well as patients with curable cancer. A new study evaluating the use of immunotherapy in patients in the perioperative setting before curative surgery has made immunotherapy plus chemotherapy a new standard of care for patients with cancer that is amenable to surgery.

How extensively is �������� Norris Comprehensive Cancer Center involved in GI cancer clinical trials?

As part of the academic health system of Keck Medicine, �������� Norris has a unique ability to offer patients a wide range of clinical trials. These trials range from phase 1 to phase 3 studies. A clinical trial can be a part of a patient’s journey at any point, from initial diagnosis to the point when standard-of-care treatments aren’t an option. These trials span many tumor types, including colorectal, gastric, esophageal, cholangiocarcinoma, pancreatic, liver and neuroendocrine tumors.

Our portfolio of clinical trials for gastrointestinal malignancies specifically includes more than 50 therapeutic trials. Our early-phase studies include 30 to 40 phase 1 studies assessing new drugs or new drug combinations, giving patients access to novel care. Our portfolio includes cutting-edge therapies such as cell engagers, which activate immune cells and bring them to the tumor; antibody-drug conjugates, which deliver chemotherapy in a more precise manner directly to the tumor; and new targeted therapies that go after genes previously thought to be “undruggable,” like RAS and p53. This extensive trial portfolio across gastrointestinal malignancies, novel agents and novel drug combinations can be relevant to a patient throughout their journey, from first-line and second-line treatment and beyond — and even in the setting where they may not have other treatment options.

Also, it’s important to know that although each of our GI oncologists may lead a particular clinical trial, all of our patients have access to any of our team’s studies.

You are the principal investigator on many GI cancer trials at �������� Norris. Can you discuss some of them?

We have several first-line studies for patients with newly diagnosed disease. For example, we have a first-line study for patients with advanced gastric cancer or gastroesophageal (GE) junction cancer that looks at combining chemotherapy with the hematopoietic progenitor kinase 1 (HPK1) inhibitor, which has synergistic, immunostimulating properties added to standard-of-care immunotherapy and chemotherapy drugs.

Another is a first-line treatment available for the treatment of esophagogastric cancer, looking at the combination of chemotherapy, immunotherapy and the investigational drug pumitamig. Pumitamig is an antibody-drug conjugate (ADC) whose mechanism of action is both immunotherapeutic (PD-1) and targeting blood vessel formation in the cancer (VEGF). Pumitamig is a new class of drug called bispecific antibody targeting. In addition, we have other trials that are targeted to HER2 and CLDN 18.2.

What should patients and their providers know about clinical trial eligibility?

We want to make sure they know that many of these trials require that patients not have initiated treatment before being evaluated for a clinical trial. So, for instance, if a patient is newly diagnosed with GI cancer and has already started standard-of-care therapy with their local oncologist, they might not be eligible to participate in a clinical trial.

If patients think they might become interested in participating in a study, it’s important that they explore those avenues before starting standard-of-care treatment. If this does not happen, there are still opportunities for trials later in their journey, so a consultation to discuss trial options is appropriate at any time.

All candidates for clinical trials are first screened to determine if they meet certain criteria and are eligible to participate. This includes tumor profiling. It’s always helpful, but not necessary, if these tumor profiles have been done before patients see us. This way, we can identify appropriate studies efficiently. If a patient has already been referred to �������� Norris, screening is done pretty quickly to determine if a patient may be eligible for a trial.

What if a patient is deemed ineligible?

We’re always happy to provide the patient with a second opinion and send them back to their referring provider for treatment, or we can continue to guide them through current treatment options here at �������� Norris.

What are some common misconceptions patients have about clinical trials?

Some misconceptions may be that a patient enrolled in a clinical trial might not be receiving optimal treatment or might receive placebo drugs without any activity for their cancer. However, most clinical trials provide some level of therapy and usually, at minimum, standard-of-care treatment as an arm.

Some patients also wonder if clinical trials are safe, especially phase 1, 2 or 3 trials involving newer drugs. They should know that these trials — and especially phase 1 trials — involve very significant monitoring. If there is any indication that drugs are not going to be safe or are going to have increased side effects, adjustments are made immediately. Trial investigators meet on a weekly, if not biweekly, basis to review patient side effects and responses to treatment.

Finally, during a clinical trial, nothing is done without clear, informed consent from the patient. Both the patient and their clinician make educated, shared decisions together.

Why is it important for patients to consider participating in clinical trials?

It’s remarkable that currently only approximately 5% of patients who are diagnosed with cancer participate in clinical trials. Exploring clinical trials is such a good opportunity for patients and their physicians to learn about what treatments are out there and to potentially access new drugs and new drug combinations that may offer an opportunity to yield better outcomes.

And, of course, clinical trials are how we make advances in care, so all participants are contributing to moving cancer care forward. The fact that only 5% of patients currently participate in studies is a huge loss for the medical community and a huge opportunity loss for patients.

No matter what, patients should at least be aware that clinical trials are an option and to make sure to leave the door open if they might want to participate. I see so many patients frustrated when they find out they can’t get into a study because they already started treatment. It’s unfortunate. If a patient decides not to proceed with entering a study, that’s fine, but if they have the information beforehand, they can at least make an informed, educated decision. We should allow our patients that opportunity.

The post Gastrointestinal Cancers and Clinical Trials: What Patients Need to Know Earlier On appeared first on ��������.

Florence-Damilola (Damie) Odufalu, MD, is a gastroenterologist with the �������� Digestive Health Institute, part of ��������, who specializes in inflammatory bowel disease. Dr. Odufalu treats patients at Keck Hospital of ��������, �������� Norris Cancer Hospital, �������� Verdugo Hills Hospital as well as at Keck Medicine’s newest Pasadena location at 590 S. Fair Oaks Ave.��

In the last several years, there’s been a massive surge in the treatment landscape for inflammatory bowel disease (IBD). The many treatments now approved and commercially available to patients show highly promising data for both safety and efficacy.  

As a provider, I’m thrilled by these developments. Knowing what they bring to IBD patients across the board, and how patients’ quality of life can be improved, makes this a really exciting time to be an IBD specialist.  

Many of us can only imagine how patients are feeling now that they’re able to find previously unheard-of levels of relief — without many of the complications and side effects they have faced before.  

Anti-interleukins: Targeting the problem without immunosuppression��

Anti-interleukins (anti-IL) therapies, usually monoclonal antibodies, work by binding to specific pro-inflammatory cytokines called interleukins or their receptors. This action prevents immune cells from releasing inflammatory signals, thus reducing chronic inflammation in autoimmune conditions — without suppressing the entire immune system. 

The data for anti-interleukin 23 (anti-IL-23) in particular is extremely promising, especially for IBD patients who have never been exposed to any advanced therapies or for IBD patients who have had no success with other therapies.  

Anti-interleukins are available via IV infusion plus a subcutaneous injection, or even as a subcutaneous injection as a launchpad for treatment. 

S1P and JAK inhibitors: Advanced therapy in pill form��

Sphingosine-1-phosphate (S1P) receptor modulators and janus kinase (JAK) inhibitors are a welcome new option for patients who are needle-phobic or who don’t want to undergo infusions or self-injectable medications. Available in pill form, these medications are ideal for moderate-to-severe inflammatory bowel disease. 

JAK inhibitors, in particular, are the newest mechanisms of therapy available for IBD. One JAK inhibitor, upadacitinib, is the first and only available oral advanced therapy for Crohn’s disease. 

Sometimes providers are hesitant to use this mechanism due to possible side effects associated with cardiac-related risk factors, but with careful patient selection and monitoring, patients who are a good fit for this type of drug can often go into IBD remission. 

Intestinal ultrasound: Reducing the need for colonoscopies��

The �������� Digestive Health Institute and Keck Medicine are spearheading a new imaging modality that uses ultrasound to track inflammation in the GI tract, including the stomach, small intestine, colon and rectum. 

The procedure is done in-office, requires no fasting or bowel prep and can be done on the spot. Even better, patients don’t have to drink a bowel preparatory solution as they would for a CT scan, MRI or colonoscopy.  

Currently, I’m the only Keck Medicine provider who offers this treatment. I encourage patients and their providers to learn more about it, as it allows patients to get some relief from all the colonoscopies they would otherwise need to undergo. While it doesn’t take the place of colonoscopy for colon cancer screenings, it’s a giant leap forward for IBD monitoring. 

These are just a few examples of what has become available in recent years in IBD treatment. There are far more innovations currently being researched and tested in clinical trials. With so many new treatments to offer, it gives me hope that we can help more and more patients live healthy lives and achieve whatever they’re capable of. 

The post 3 Innovations Revolutionizing IBD Treatment�� appeared first on ��������.

Barrett’s esophagus is a precancerous change in the esophagus caused by acid reflux that can eventually lead to esophageal cancer. Not everyone who develops Barrett’s esophagus will progress to esophageal cancer, but determining which patients are at high risk is critical to determining the best treatment course.

A new type of genetic analysis could enhance the ability to stratify which patients are at low, medium or high risk of developing esophageal cancer. As John C. Lipham, MD, a gastrointestinal surgeon with the �������� Digestive Health Institute, part of ��������, explains, this advanced insight makes it possible for physicians to better identify which Barrett’s esophagus patients should be treated with ablation and which patients might instead be able to be managed with ongoing medication and surveillance.

Genetics, Barrett’s esophagus and esophageal cancer

How do genetics increase the risk of developing Barrett’s esophagus or esophageal cancer? As Lipham explains, “There’s definitely a genetic link, not only to what causes acid reflux but to what puts patients at risk for developing Barrett’s esophagus or esophageal cancer.”

In short: Acid reflux is a mechanical problem caused by a weak lower esophageal sphincter (LES) that fails to prevent acid from the stomach from entering the esophagus. Genetics can predispose a person to having a weak LES. For these individuals, continued acid reflux can turn dangerous. In the long term, acid, bile and digestive enzymes from the stomach can damage the inside of the esophagus, causing ulcerations, bleeding or a stricture.

“This damage can lead to precancerous changes in the esophagus in about 15% of people,” Lipham says. “That precancerous change is called Barrett’s esophagus. It’s when the inside of the esophagus changes to a different type of lining that has a much higher risk of developing esophageal cancer. So, ultimately, reflux can lead to esophageal cancer.”

And while it’s true that lifestyle choices, such as the food one eats, can worsen acid reflux, genetics can’t be overcome. “As the weak LES worsens due to the underlying genetic or connective tissue disorder, we get to a point when it doesn’t even matter what someone eats or does,” Lipham says. “The LES becomes a wide-open door, and everything comes up no matter what you eat.”

Treating Barrett’s esophagus

Once a patient is diagnosed with Barrett’s esophagus, doctors must determine what treatment course to take. In general, there are two options.

One is to manage Barrett’s esophagus through medication that addresses reflux — such as proton pump inhibitors — and to conduct regular endoscopy checkups to monitor any dysplasia progression.

“Many patients can go their whole life with reflux and not develop esophageal cancer,” Lipham says. “Only a small percentage of people with Barrett’s esophagus will progress to cancer. If we know a patient’s risk level is low based on their genetic profile, we may opt to manage them with a proton pump inhibitor instead of performing surgery.”

The other option is to endoscopically ablate the part of the esophagus afflicted with Barret’s esophagus, such as with radiofrequency ablation or cryoablation, with the hope of lowering the risk of developing cancer. “Patients in the intermediate- or high-risk category are the ones we’re going to be more aggressive with treating by recommending ablation,” Lipham says.

The challenge, however, is determining whether a Barrett’s esophagus patient is at low, medium or high risk. This is where a newer type of genetic profiling, called spatial genomics, could help.

Spatial genomics: a new frontier in genomic testing

Spatial genomics is an emerging field of genetic profiling that evaluates cellular behavior based on the location of cells. It considers where cells are positioned within tissue relative to other cells, and through this context it studies how cells interact and behave.

In the case of Barrett’s esophagus, “spatial omics” companies are developing spatial genomics technologies to analyze biopsies of esophageal tissue to identify molecular changes that precede dysplasia, helping to identify Barrett’s esophagus cases that are more likely to progress to cancer. New testing technologies from spatial omics companies are making it possible to study and analyze cells in their natural architecture in intact tissue.

Spatial omics in practice

The enhanced ability to stratify patient risk enables a more personalized approach to care, Lipham says: “Ultimately, the genetic profile will help us to decide which treatment will work best for a patient to help prevent cancer.”

He continues: “To me it’s been a game changer in how we treat not just reflux patients but, more importantly, the Barrett’s patients. Before, we treated them all the same. If you had Barrett’s esophagus, we would just monitor you very closely, meaning you had to have an endoscopy every one to three years. But now, with our ability to stratify patients’ risk, we can tell a patient, ‘You’re at low risk. You probably don’t need to come back for another endoscopy for five years, if not more.’ And if it’s a high-risk patient, we can move to ablation and/or surgery.”

Lipham has already seen the benefits in action. In one instance, he and his colleagues were diagnosing a patient who had developed a small area of Barrett’s esophagus. A biopsy sent to a standard pathology lab classified the patient as non-dysplastic and low risk. Lipham and his colleagues, however, had also sent a biopsy to a spatial omics testing lab. The spatial omics technology deemed the patient very high risk, with a 25% risk of progressing to cancer.

Based on the spatial omics results, Lipham says, “We elected to do additional endoscopy and biopsies to make sure we weren’t missing anything. Indeed, in those additional biopsies, we ended up fing an early cancer that we couldn’t see with the naked eye. Luckily, it was caught early enough that we were able to treat the patient endoscopically, ablating the Barrett’s area away so that they didn’t have to undergo a major surgery like esophagectomy for cancer.”

Lipham predicts that spatial omics will become the standard of care for Barrett’s esophagus patients. “This has been the biggest game changer I’ve seen so far in terms of diagnostics and trying to decrease esophageal cancer mortality or development. Not only does it help us identify the patients who are at risk of developing cancer, the patients who need intervention sooner than later, but it also identifies the patients who are at low risk who don’t need more drastic intervention. It allows us to deescalate their care so they can just be treated with antacids and less-frequent checkups,” he says.

He adds, “When presented with a patient with bad reflux, Barrett’s esophagus or even early esophageal cancer, it’s important to send the patient to a place like the �������� Digestive Health Institute which specializes in treatment, where we not only have a deep understanding of these conditions but also have access to some of these newer diagnostic tests and treatment options.”

The post Will Spatial Genomics Help Identify Barrett’s Esophagus Patients at High Risk of Esophageal Cancer? appeared first on ��������.

One of the biggest hurdles in treating the obesity epidemic is the stigma around discussing and treating obesity like what it is: a chronic disease.

“Obesity is one of the last remaining stigmas socially, but one of the highest remaining areas of stigmatization in medicine,” says Kamran Samakar, MD, general surgeon and director of the �������� Metabolic and Bariatric Surgery Program, part of the �������� Digestive Health Institute and ��������. “If you look at studies and you ask patients with obesity, ‘Do you wish your primary care doctor or your other doctors discussed this with you?’ around 75%-80% of these people — a resounding majority — will say, ‘Yes, I wish they would talk to me about treatment options.’”

His takeaway advice to physicians? “Don’t be scared to talk to your patients about obesity.”

Sensitivity and stigma training for obesity

The clinicians and staff with Keck Medicine are routinely trained on how to address obesity sensitivity and stigma. “We do this to make sure people understand how to speak about obesity in a way that’s very sensitive, nuanced and patient-centered,” says Samakar, who specializes in bariatric and gastrointestinal procedures.

If you’re an independent physician, are available on how to have medical conversations about obesity with patients. This foundation helps physicians become savvier, sophisticated and sensitive when discussing the topic, which can be difficult or highly personal to a patient.

Improving your approach benefits all. “These conversations are overlooked and underemphasized,” Samakar says. “As a result, lack of conversations, or bad conversations, can be a barrier to proper care for the disease.”

How to recommend obesity treatments

While bariatric surgery is the most durable and effective treatment for obesity, Samakar’s advice is to not immediately recommend bariatric surgery to every patient right off the bat.

“Talk to your patients about obesity, and let them know there are options,” he says. “Not everyone necessarily needs to have bariatric surgery, but we have tools available to treat obesity like any other disease. The most important thing is to let patients know they deserve treatment and that it’s available to them. From there, the exact treatment route can be personalized to their needs.”

Many patients have fears about treating their obesity, whether that’s fear around having surgery or of side effects from weight loss medications like semaglutide or tirzepatide. One of the most important things doctors can do in this situation is to remind their patients that all these side effects are less dangerous than letting obesity go unchecked, Samakar says.

“When you look at the risks associated with obesity and obesity-associated metabolic diseases, you’re more likely to have a lower quality of life, more likely to have cardiac events and more likely to have premature death if you do nothing to treat it,” Samakar says. “Those are all significantly greater risks than the risks presented by the treatment of obesity.”

Discussing all concerns openly, including statistics of complications from bariatric surgery, can actually help encourage patients to seek treatment, he adds.

“The risk of significant bleeding that requires a return to the operating room is less than 1%,” Samakar says. “The risk of death from bariatric surgery at an accredited center in the United States is less than one in 1000. These are very good numbers compared to the data for complications from obesity.” By contrast, the most common causes of death in the United States are cardiac disease and cancer — both of which are strongly related to obesity.

“I remind patients that doing nothing to treat your obesity is actually doing something to your disease: it’s letting it go uncontrolled,” he says.

Treating obesity holistically

The most important place to start in these conversations is to focus on a comprehensive treatment plan. “We don’t just want to focus on one aspect of obesity, such as making the number on the scale go down,” Samakar says. “We want people to have a functional experience that’s improved.”

This might mean yes, the number on the scale goes down, he says. But it’s also crucial to focus on non-scale victories that relate to quality of life. For example, if the patient can finally play with their grandchildren, or walk up the stairs, or go to Disneyland with their family and not have to sit down every hour, he explains.

Helping patients view the benefits of obesity treatment through a broader lens is more likely to help them succeed in the long-term.

“We need to help people curate the things they must do to live healthier lives apart from only prescriptive recommendations to sleep better, eat better and stress less,” Samakar says. “At obesity centers such as the �������� Digestive Health Institute, we address the disease from a holistic angle so that we aren’t just giving patients a short-term fix. Instead, we can offer them a multipronged treatment approach that considers all aspects of care, including occupational or physical therapy to help increase muscle mass, dietary and lifestyle modifications through nutritional counseling, and pharmaceutical and surgical interventions for weight loss.”

And remember: Even if your words around obesity treatment aren’t perfect, patients have a way of knowing the intent behind them. This matters more, Samakar says.

“Most patients are able to understand and feel your intention,” he says. “So, if you’re coming from a place of wanting to help your patients achieve better health, I think overall that’s the intent we are looking for and the most important point to remember when discussing obesity treatment with your patients.”

The post Ending Medical Stigma: How to Talk to Your Patients About Obesity Treatment appeared first on ��������.

When people think of inflammatory bowel diseases (IBD) like ulcerative colitis or Crohn’s disease, common symptoms like abdominal pain, constipation and diarrhea come to mind. Fewer realize, however, that IBD can be a very complex disease, requiring a high level of customized care.

When patients present with more severe disease, a multidisciplinary treatment approach may be needed, says Sarah Sheibani, MD, a gastroenterologist specializing in IBD. Sheibani co-leads the �������� Inflammatory Bowel Disease Center, part of the �������� Digestive Health Institute and ��������.

Together, these specialists can optimize treatment and support the patient from all angles, Sheibani says. She outlines which medical providers might be part of a multifaceted IBD team.

Why can IBD be complex?

“IBD ranges from simple to very complex,” Sheibani explains. “It can span mild inflammation in the colon that causes minor symptoms like diarrhea or abdominal pain; or it can present with more severe inflammation that can lead to fistulization, where the bowel connects to other organs or other parts of the bowel; or it could lead to perforation, which is a hole in the colon or the small bowel.”

Adversity can extend beyond the bowel, not only to the esophagus and stomach but to other areas of a patient’s body. Sometimes, IBD symptoms can be so debilitating that patients can’t go to work or to school. It can also interfere with their relationships.

One of the frustrating facts about IBD is that it often manifests in young people and those of childbearing age. “It can affect their day-to-day during a time in their life when they are trying to finish school, get married or start a family. We treat many college students here at Keck Medicine,” Sheibani adds.

Because of this, she says, “You also have to think beyond the physical and address the psychosocial impacts of this disease, like anxiety and depression.”

Tertiary IBD care

This is the very reason why many physicians end up referring their IBD patients to a specialty digestive care center like the �������� Inflammatory Bowel Disease Center. Their patients need this level of specialized, multidisciplinary care.

Sheibani says these patients often already have a diagnosis, and their physician needs help from specialists to treat the disease. “The majority of our patients are referrals from other gastroenterologists in the community seeking a second opinion or more support in providing the multidisciplinary type of care that some of these patients require,” Sheibani says.

Which IBD specialists might patients need?

At the �������� Inflammatory Bowel Disease Center, the care team includes gastroenterologists, colorectal surgeons, pathologists, radiologists and nutritionists who specialize in treating IBD.

Academic medical centers are also likelier to be at the forefront of noninvasive diagnostic imaging, such as intestinal ultrasounds, to diagnose and stage IBD. “Here at Keck Medicine, we are starting an intestinal ultrasound program and will be able to restage disease in-clinic,” she adds.

If, when surgery is needed, “That’s where the expertise of our colorectal surgeons comes into play,” she says.

This disease often requires complex surgery. For this reason, she says, “You want to be referred to a center that has a lot of expertise in IBD surgery.” The co-leader of the �������� Inflammatory Bowel Disease Center, Sang Lee, MD, chief of the �������� Colorectal Surgery Program at Keck Medicine, and his colleagues specialize in performing these complex IBD surgeries, she says.

Not only that, but our surgeons are experts in laparoscopic procedures. With conditions like IBD, Sheibani says, “You want to do surgery in the most minimally invasive way possible to reduce hospital stay and long-term complications.”

The �������� Inflammatory Bowel Disease Center also draws on the expertise of physicians knowledgeable about new medications to treat IBD. “We have access to clinical trials for patients who are not responding to available therapies. This may give patients an opportunity to try another medication before considering surgery.”

Specialties unite to treat IBD

Other specialists can also be integral in treating complex IBD cases. “Because IBD has a lot of extraintestinal manifestations that are not just GI-related, you need the support of other doctors besides surgeons,” Sheibani says.

Take dermatologists. “A lot of our dermatologists specialize in IBD-associated skin conditions that can be very challenging to treat,” Sheibani says. “If such a patient is referred to me with an IBD-related skin condition such as pyoderma gangrenosum, I’ll co-manage their case with one of our dermatologists.”

The same goes for rheumatologists when it comes to conditions such as IBD-associated arthritis. “I’ll refer the patient to one of our rheumatologists to help manage the joints, and we work together to find the right therapy,” she says.

Finally, other ancillary providers round out comprehensive care for IBD patients. Nutritionists with IBD expertise can guide patients who are malnourished, have vitamin deficiencies or are continuing to experience symptoms. And psychologists can help address the psychosocial impacts of this chronic, debilitating disease.

Sheibani notes that all the IBD specialists at the center learn from each other by discussing the most complex patient cases at multidisciplinary conferences every month.

Co-managing the patient

Sheibani emphasizes that in many circumstances, the �������� Inflammatory Bowel Disease Center works together with a patient’s own physician to “co-manage” the patient’s disease.

“We can help address complex issues and relay them back to the primary GI,” she says. “We work with them and provide advice and guidance when needed. We always strive to keep the lines of communication open with the patient’s primary gastroenterologist.”

The post Inflammatory Bowel Disease: Why Complex IBD Cases Need Multidisciplinary Care appeared first on ��������.

Gastroesophageal reflux disease’s (GERD) main causes are a faulty lower esophageal sphincter and/or a hiatal hernia. While physicians often assume the lower esophageal sphincter is to blame, research now shows hiatal hernias cause a higher percentage of GERD.

“Over time, we’ve realized that hiatal hernias account for about 70% of reflux,” says John C. Lipham, MD, a gastrointestinal surgeon with the �������� Digestive Health Institute, part of ��������.

Surgery may be performed if a hiatal hernia is causing chronic reflux. Unfortunately, even after surgical repair, hiatal hernias often recur.

Is there a better way to treat GERD, one that prevents hiatal hernias from returning? This is what Lipham and Keck Medicine researchers are studying in a clinical trial.

What is a hiatal hernia?

A hiatal hernia develops when there is a weaknesses in the diaphragm muscle separating the thoracic and abdominal cavities. This muscle can weaken so that the upper portion of the stomach ends up pushing up and eventually through a small opening in the diaphragm (the hiatus).

Patients, especially those with a large hiatal hernia, may experience acid reflux symptoms as acid and bile flow back into the esophagus. Symptoms include heartburn, regurgitation, chest or abdominal pain, and dysphagia.

If a hiatal hernia is causing chronic GERD, treating it is important because ongoing GERD can eventually cause Barrett’s esophagus, which leads to an increased risk of esophageal cancer.

Surgery can repair a hiatal hernia. “Traditionally, we suture the hole in the diaphragm closed and place mesh over the repair,” Lipham says.

New approach to treat a hiatal hernia

Unfortunately, 30%-50% of hiatal hernias redevelop even after surgical repair. “When surgeries fail, it’s usually due to recurrence of the hiatal hernia,” Lipham says. “In fact, 85%-95% of the time when someone develops recurrent reflux again after surgery it’s because of recurrence of the hernia.”

The mesh placed over a repaired hernia does not stop the hernia from redeveloping. “The mesh has never been shown to decrease recurrence rates,” Lipham says. “Despite this, people keep trying different types of mesh — biologic mesh, synthetic mesh, porcine mesh, you name it — to see if it will somehow result in a lower recurrence rate. Unfortunately, it hasn’t.”

Lipham and Keck Medicine researchers are focusing their research on how to prevent hiatal hernias from returning.

In a prospective, randomized controlled , they are studying whether platelet-rich plasma can improve wound healing and resolve hernias long-term. The use of platelet-rich plasma isn’t new; it’s already a treatment in orthopedics and dermatology.

In their study taking place at Keck Medicine, Lipham and his colleagues will treat participants’ hiatal hernias. One group will receive a standard mesh repair, while a second group will receive mesh treated with platelet-rich plasma.

“Research shows that the reason people develop a hiatal hernia is because they have a collagen deficiency in the connective tissue of that area,” Lipham explains. “That deficiency allows the hole in the diaphragm to stretch out, which leads to hernias forming. But even if we sew the hole closed, the fact remains that we’re sewing deficient tissue back together. And because of the deficiency, it doesn’t heal as tightly or as well as it should. Applying the platelet-rich plasma will increase collagen deposition. This will encourage connective tissue to grow to help keep the area together, lowering the chance of a hernia recurring.”

Lipham says this is the first prospective randomized controlled trial to test platelet-rich plasma in hiatal hernia repair.

New frontier for GERD treatment

Lipham hopes this research gets the medical community thinking about a new approach to treating hiatal hernias: stimulating better wound healing to prevent recurrence.

He also believes more physicians will come to realize the outsized role hiatal hernias play in GERD. “Until now, everyone’s put their research money on better ways to fix the lower esophageal sphincter. But at the end of the day, they all fail because of the recurrence of the hiatal hernia,” he says. “To this day, I think there are many who don’t even realize that hiatal hernias are part of the disease, and they definitely don’t realize how much of the disease hernias are responsible for.”

As more providers come to understand that hernias are responsible for 70% of GERD, more funding will be spent on research targeting hernia repair and recurrence.

“So maybe platelet-rich plasma won’t be 100% of the answer, but I think it will stimulate others to look at other ways to improve wound healing to prevent recurrence of the hernia,” Lipham concludes.

The post Is Stopping Hiatal Hernia Recurrence the Key to Curing GERD? appeared first on ��������.

As artificial intelligence improves, gastroenterologists are asking whether AI can soon play a larger role in their practice. A new study by researchers from �������� and the Keck School of Medicine of �������� examined whether a large language model can accurately predict when patients should get their next colonoscopy.

Study design

Today, primary care physicians and gastroenterologists advise patients when to get screened for colorectal cancer. To make their recommendations, these experts consider several factors, including colonoscopy results, pathology results, risk factors for the disease as well as established, general-population screening guidelines.

But what if AI could make those recommendations instead?

In their study published in , researchers from the Keck School of Medicine of �������� fed large language model ChatGPT-4 the following data:

• Verbatim text from patients’ clinical, procedural and pathology reports
• Individualized patient data (age, gender, history of past illness, family history of disease, information from their last medical visit)

Study subjects were patients aged 18 or older who had undergone colorectal cancer screening with either �������� or Los Angeles General Medical Center. The study excluded patients with serious gastrointestinal conditions such as cancer, inflammatory bowel disease and hereditary polyposis syndromes.

Researchers fed ChatGPT-4 the information and the system to generate recommendations for when the patients should get follow-up colonoscopies based on 2020 screening guidelines from the U.S. Multi-Society Task Force (USMSTF). They then compared the AI recommendations with recommendations generated by both human physicians and the USMSTF.

“This is the first investigation to study ChatGPT-4 for its accuracy and concordance of recommendations on rescreening and surveillance colonoscopy intervals compared to USMSTF guidelines,” researchers added.

Promising results

The results were positive. When researchers compared ChatGPT-4 and USMSTF screening recommendations, they found the two aligned in 85.7% of cases. In fact, USMSTF screening recommendations were more often in line with recommendations from ChatGPT-4 than recommendations from human physicians. Real-life physician recommendations gathered from medical records matched USMSTF guidelines in only 75.4% of cases.

ChatGPT-4’s performance is especially notable given the large breadth of unorganized, verbatim patient-specific data it was fed. The fact that it could make accurate predictions using this data shows promise for clinical use of large language models.

“Initial real-world results suggest that ChatGPT-4 can accurately define routine colonoscopy screening intervals based on verbatim input of clinical data,” the researchers said.

The future of AI in colorectal screening

Currently, AI’s main application in the gastroenterology field has been in assisting with polyp detection, says Ara Sahakian, MD, a gastroenterologist with the �������� Digestive Health Institute, part of Keck Medicine, and the senior lead study author. “It helps to avoid missing things and improves the accuracy of diagnosis,” he says.

But one shouldn’t overlook AI’s potential to reduce the time and cost of what Sahakian calls the “workflow side” of clinical care. Such care includes ensuring patients get follow-up, which involves substantial interaction with the patient, including discussion of results, scheduling and authorizations.

“Our study shows where this type of large language model could potentially be built into our electronic health records,” Sahakian says. “It could scan a patient’s pathology, endoscopy and clinical chart data and automatically send a reminder to the patient and physician when it’s time for the next colonoscopy.”

Also consider the fact that the AI engine in this study was not specifically designed around health care. If it were, “it could be even more accurate and powerful for this purpose,” he says. “You can imagine that with this type of powerful AI engine, it doesn’t need to be a doctor doing all the data input and work. Our staff could input the data. It could create a lot of efficiency.”

As AI’s accuracy and data improves, it can reduce the time and cost of day-to-day clinical operations. “After further optimization, [large language models] have potential to extend the clinician’s abilities,” Sahakian and his coauthors state.

Physician oversight is still undoubtedly key. “We do need experts to review everything and make sure the recommendations made by AI are accurate,” Sahakian says. “AI is going to change the game in terms of what we do in detection, diagnosis and workflow. It’s going to make our jobs easier. It’s going to make us faster, better and more accurate at what we do.”

The post Can AI Correctly Predict When Patients Need Their Next Colonoscopy? appeared first on ��������.

Traditionally, heart and liver transplants are performed using donors categorized as “brain-dead.” These donors no longer have brainstem reflexes, yet they maintain function in their hearts and other organs.

Although this donor pool has been ideal for securing usable organs, the availability of these organs isn’t enough to meet a growing need as heart and liver failure cases rise across the country.

A cutting-edge approach known as normothermic regional perfusion (NRP) is allowing transplant teams to explore a much broader range of organ donors — and early cases in the U.S. show promising results.

Perfusing the heart after circulatory death

In June 2023, Raymond Lee, MD, a cardiac surgeon at the �������� Transplant Institute, part of ��������, used the NRP technique to successfully transplant a heart into a 62-year-old patient with non-ischemic cardiomyopathy.

With NRP, surgeons transplant organs donated after circulatory death rather than brain death. These donors have experienced catastrophic neurological injuries but are not labeled brain-dead because they still maintain some reflexes.

“When the breathing tube is removed and the patient has cardiac arrest, somewhere between five to 10 minutes can pass beyond brain death before we can declare circulatory death,” Lee said. “We’re then able to perform an NRP heart procurement.”

Immediately after circulatory death, Lee opened the donor’s chest, placed the body on cardiopulmonary bypass and drained all the blood from the heart. He and his team then began perfusing the body while cutting off blood flow to the brain.

“We watched the heart come back to see if it was usable again after the cardiac death,” Lee said. “Once we saw that it was, we started preparing our recipient.”

Lee proceeded with transplanting the heart into the 62-year-old recipient at Keck Hospital of ��������. The patient was discharged from the hospital about a month later in good condition.

Liver procurement from NRP donor

Using the same NRP donor that Lee’s heart transplant team perfused, a Keck Medicine liver transplant team also performed a successful transplant.

The recipient, who was experiencing liver failure, had been on the transplant list for less than a year.

Transplant teams have traditionally avoided NRP livers because of the stress placed on abdominal organs in the period after circulatory death.

However, with Lee’s perfusion, the donor heart quickly reestablished warm, oxidized blood flow to the liver.

“It really resuscitated the organ,” said the Keck Medicine liver transplant surgeon who performed the procedure. “It allowed the liver to recover before it had to go on ice.”

Additionally, the liver transplant team targeted a recipient they assessed would do well with an organ that had undergone the added stress.

The recipient was farther down on the transplant list than most recipients from brain-dead donors — and therefore healthy enough to endure it.

“The organ undergoes one major stress in the procurement process,” the liver transplant surgeon added. “You can’t then put it into somebody who’s severely ill to the level of needing treatment in the ICU.”

With these guidelines in mind, the transplant was a success.

“This organ has the potential to last the recipient for the rest of his life — 40 to 50 years, potentially,” said the surgeon. “With continued follow-up and ongoing immunosuppressant medication, we consider him cured of his liver disease.”

‘The future of transplant’

According to Lee, the NRP technique offers transplant surgeons the chance to expand opportunities for patients in need. It’s potentially an organ pool that could be much larger than the traditional pool, especially considering that many more people die in a fashion consistent with cardiac death than with brain death.

In August 2023, the heart transplant team performed their second successful NRP transplant at Keck Hospital.

Their partnership with the abdominal organ transplant teams of the �������� Transplant Institute allows greater collaboration for future liver and kidney transplants as well. It’s the future of transplant, the experts say, allowing the institute to use NRP to take organs that were previously challenging and marginally unsafe to use and bring them to the safety level of standard transplants.

�������� Transplant Institute

The �������� Transplant Institute team takes a complete approach to caring for transplant patients and living organ donors. We make sure your patients have a team of experts on their side every step of the way, from evaluation to recovery.

The post Normothermic Regional Perfusion Expands Organ Transplant Availability appeared first on ��������.