GI and Hepatology News

A new study adds to what has been emerging in the literature — namely that there appear to be gut microbiome “signatures” for various pain conditions — suggesting that microbiome-based diagnostics and therapeutics may one day be routine for a broad range of pain conditions.

“There is now a whole list of pain conditions that appear to have these signatures, including postoperative pain, arthritis, neuropathy and migraine to name a few,” Robert Bonakdar, MD, director of pain management, Scripps Center for Integrative Medicine, San Diego, told GI & Hepatology News.

Fibromyalgia and complex regional pain syndrome (CRPS) are also on the list.

A team led by Amir Minerbi, MD, PhD, director of the Institute for Pain Medicine, Haifa, Israel, and colleagues published one of the first articles on gut changes in fibromyalgia. They noted that the gut microbiome could be utilized to determine which individuals had the condition and which did not — with about a 90% accuracy.

The team went on to show that transplanting gut microbiota from patients with fibromyalgia into germ-free mice was sufficient to induce pain-like behaviors in the animals — “effects that were reversed when healthy human microbiota were transplanted instead,” Minerbi told GI & Hepatology News.

Further, in a pilot clinical study, the researchers showed that transplanting microbiota from healthy donors led to a reduction in pain and other symptoms in women with treatment-resistant fibromyalgia.

Most recently, they found significant differences in the composition of the gut microbiome in a cohort of patients with CRPS from Israel, compared to matched pain-free control individuals.

Notably, two species — Dialister succinatiphilus and Phascolarctobacterium faecium – were enriched in patients with CRPS, while three species — Ligilactobacillus salivarius, Bifidobacterium dentium, and Bifidobacterium adolescentis – were increased in control samples, according to their report published last month in Anesthesiology.

“Importantly,” these findings were replicated in an independent cohort of patients with CRPS from Canada, “suggesting that the observed microbiome signature is robust and consistent across different environments,” Minerbi told GI & Hepatology News.

 

Causal Role? 

“These findings collectively suggest a causal role for the gut microbiome in at least some chronic pain conditions,” Minerbi said.

However, the co-authors of a linked editorial cautioned that it’s “unclear if D succinatiphilus or P faecium are functionally relevant to CRPS pathophysiology or if the bacteria increased in healthy control samples protect against CRPS development.”

Minerbi and colleagues also observed that fecal concentrations of all measured short chain fatty acids (SCFA) in patients with CRPS were lower on average compared to pain-free control individuals, of which butyric, hexanoic, and valeric acid showed significant depletion.

Additionally, plasma concentrations of acetic acid showed significant depletion in patients with CRPS vs control individuals, while propionate, butyrate, isobutyrate and 2-methyl-butyric acid showed a trend toward lower concentrations.

The quantification of SCFA in patient stool and serum is a “notable advance” in this study, Zulmary Manjarres, PhD; Ashley Plumb, PhD; and Katelyn Sadler, PhD; with the Center for Advanced Pain Studies at The University of Texas at Dallas, wrote in their editorial.

SCFA are produced by bacteria as a byproduct of dietary fiber fermentation and appropriate levels of these compounds are important to maintain low levels of inflammation in the colon and overall gut health, they explained.

This begs the question of whether administering probiotic bacteria — many of which are believed to exert health benefits through SCFA production — can be used to treat CRPS-associated pain. It’s something that needs to be studied, the editorialists wrote.

Yet, in their view, the “most notable achievement” of Minerbi and colleagues is the development of a machine learning model that accurately, specifically and sensitively categorized individuals as patients with CRPS or control individuals based on their fecal microbiome signature.

The model, trained on exact sequence variant data from the Israeli patients, achieved 89.5% accuracy, 90.0% sensitivity, and 88.9% specificity in distinguishing patients with CRPS from control individuals in the Canadian cohort.

Interestingly, in three patients with CRPS who underwent limb amputation and recovered from their pain, their gut microbiome signature remained unchanged, suggesting that microbiome alterations might precede or persist beyond symptomatic phases.

 

Test and Treat: Are We There Yet? 

The gut microbiome link to chronic pain syndromes is a hot area of research, but for now gut microbial testing followed by treatment aimed at “fixing” the microbiome remains largely experimental.

At this point, comprehensive gut-microbiome sequencing is not a routine, guideline-supported part of care for fibromyalgia or any chronic pain condition.

“Unfortunately, even for doctors interested in this area, we are not quite at the state of being able to diagnose and treat pain syndrome based on microbiome data,” Bonakdar told GI & Hepatology News.

He said there are many reasons for this including that this type of microbiome analysis is not commonly available at a routine lab. If patients do obtain testing, then the results are quite complex and may not translate to a diagnosis or a simple microbiome intervention.

“I think the closest option we have now is considering supplementing with commonly beneficial probiotic in pain conditions,” Bonakdar said.

One example is a preliminary fibromyalgia trial which found that supplementing with Lactobacillus, Bifidobacterium, and Saccharomyces boulardii appeared to have benefit.

“Unfortunately, this is hit or miss as other trials such as one in low back pain did not find benefit,” Bonakdar said.

Addressing gut microbiome changes will become “more actionable when microbiome analysis is more commonplace as well as is the ability to tailor treatment to the abnormalities seen on testing in a real-world manner,” Bonakdar said.

“Until then, there is no harm in promoting an anti-inflammatory diet for our patients with pain which we know can improve components of the microbiome while also supporting pain management,” he concluded.

Minerbi, Bonakdar, and the editorial writers had no relevant disclosures.

A version of this article appeared on Medscape.com.

A new study adds to what has been emerging in the literature — namely that there appear to be gut microbiome “signatures” for various pain conditions — suggesting that microbiome-based diagnostics and therapeutics may one day be routine for a broad range of pain conditions.

“There is now a whole list of pain conditions that appear to have these signatures, including postoperative pain, arthritis, neuropathy and migraine to name a few,” Robert Bonakdar, MD, director of pain management, Scripps Center for Integrative Medicine, San Diego, told GI & Hepatology News.

Fibromyalgia and complex regional pain syndrome (CRPS) are also on the list.

A team led by Amir Minerbi, MD, PhD, director of the Institute for Pain Medicine, Haifa, Israel, and colleagues published one of the first articles on gut changes in fibromyalgia. They noted that the gut microbiome could be utilized to determine which individuals had the condition and which did not — with about a 90% accuracy.

The team went on to show that transplanting gut microbiota from patients with fibromyalgia into germ-free mice was sufficient to induce pain-like behaviors in the animals — “effects that were reversed when healthy human microbiota were transplanted instead,” Minerbi told GI & Hepatology News.

Further, in a pilot clinical study, the researchers showed that transplanting microbiota from healthy donors led to a reduction in pain and other symptoms in women with treatment-resistant fibromyalgia.

Most recently, they found significant differences in the composition of the gut microbiome in a cohort of patients with CRPS from Israel, compared to matched pain-free control individuals.

Notably, two species — Dialister succinatiphilus and Phascolarctobacterium faecium – were enriched in patients with CRPS, while three species — Ligilactobacillus salivarius, Bifidobacterium dentium, and Bifidobacterium adolescentis – were increased in control samples, according to their report published last month in Anesthesiology.

“Importantly,” these findings were replicated in an independent cohort of patients with CRPS from Canada, “suggesting that the observed microbiome signature is robust and consistent across different environments,” Minerbi told GI & Hepatology News.

 

Causal Role? 

“These findings collectively suggest a causal role for the gut microbiome in at least some chronic pain conditions,” Minerbi said.

However, the co-authors of a linked editorial cautioned that it’s “unclear if D succinatiphilus or P faecium are functionally relevant to CRPS pathophysiology or if the bacteria increased in healthy control samples protect against CRPS development.”

Minerbi and colleagues also observed that fecal concentrations of all measured short chain fatty acids (SCFA) in patients with CRPS were lower on average compared to pain-free control individuals, of which butyric, hexanoic, and valeric acid showed significant depletion.

Additionally, plasma concentrations of acetic acid showed significant depletion in patients with CRPS vs control individuals, while propionate, butyrate, isobutyrate and 2-methyl-butyric acid showed a trend toward lower concentrations.

The quantification of SCFA in patient stool and serum is a “notable advance” in this study, Zulmary Manjarres, PhD; Ashley Plumb, PhD; and Katelyn Sadler, PhD; with the Center for Advanced Pain Studies at The University of Texas at Dallas, wrote in their editorial.

SCFA are produced by bacteria as a byproduct of dietary fiber fermentation and appropriate levels of these compounds are important to maintain low levels of inflammation in the colon and overall gut health, they explained.

This begs the question of whether administering probiotic bacteria — many of which are believed to exert health benefits through SCFA production — can be used to treat CRPS-associated pain. It’s something that needs to be studied, the editorialists wrote.

Yet, in their view, the “most notable achievement” of Minerbi and colleagues is the development of a machine learning model that accurately, specifically and sensitively categorized individuals as patients with CRPS or control individuals based on their fecal microbiome signature.

The model, trained on exact sequence variant data from the Israeli patients, achieved 89.5% accuracy, 90.0% sensitivity, and 88.9% specificity in distinguishing patients with CRPS from control individuals in the Canadian cohort.

Interestingly, in three patients with CRPS who underwent limb amputation and recovered from their pain, their gut microbiome signature remained unchanged, suggesting that microbiome alterations might precede or persist beyond symptomatic phases.

 

Test and Treat: Are We There Yet? 

The gut microbiome link to chronic pain syndromes is a hot area of research, but for now gut microbial testing followed by treatment aimed at “fixing” the microbiome remains largely experimental.

At this point, comprehensive gut-microbiome sequencing is not a routine, guideline-supported part of care for fibromyalgia or any chronic pain condition.

“Unfortunately, even for doctors interested in this area, we are not quite at the state of being able to diagnose and treat pain syndrome based on microbiome data,” Bonakdar told GI & Hepatology News.

He said there are many reasons for this including that this type of microbiome analysis is not commonly available at a routine lab. If patients do obtain testing, then the results are quite complex and may not translate to a diagnosis or a simple microbiome intervention.

“I think the closest option we have now is considering supplementing with commonly beneficial probiotic in pain conditions,” Bonakdar said.

One example is a preliminary fibromyalgia trial which found that supplementing with Lactobacillus, Bifidobacterium, and Saccharomyces boulardii appeared to have benefit.

“Unfortunately, this is hit or miss as other trials such as one in low back pain did not find benefit,” Bonakdar said.

Addressing gut microbiome changes will become “more actionable when microbiome analysis is more commonplace as well as is the ability to tailor treatment to the abnormalities seen on testing in a real-world manner,” Bonakdar said.

“Until then, there is no harm in promoting an anti-inflammatory diet for our patients with pain which we know can improve components of the microbiome while also supporting pain management,” he concluded.

Minerbi, Bonakdar, and the editorial writers had no relevant disclosures.

A version of this article appeared on Medscape.com.

A new study adds to what has been emerging in the literature — namely that there appear to be gut microbiome “signatures” for various pain conditions — suggesting that microbiome-based diagnostics and therapeutics may one day be routine for a broad range of pain conditions.

“There is now a whole list of pain conditions that appear to have these signatures, including postoperative pain, arthritis, neuropathy and migraine to name a few,” Robert Bonakdar, MD, director of pain management, Scripps Center for Integrative Medicine, San Diego, told GI & Hepatology News.

Fibromyalgia and complex regional pain syndrome (CRPS) are also on the list.

A team led by Amir Minerbi, MD, PhD, director of the Institute for Pain Medicine, Haifa, Israel, and colleagues published one of the first articles on gut changes in fibromyalgia. They noted that the gut microbiome could be utilized to determine which individuals had the condition and which did not — with about a 90% accuracy.

The team went on to show that transplanting gut microbiota from patients with fibromyalgia into germ-free mice was sufficient to induce pain-like behaviors in the animals — “effects that were reversed when healthy human microbiota were transplanted instead,” Minerbi told GI & Hepatology News.

Further, in a pilot clinical study, the researchers showed that transplanting microbiota from healthy donors led to a reduction in pain and other symptoms in women with treatment-resistant fibromyalgia.

Most recently, they found significant differences in the composition of the gut microbiome in a cohort of patients with CRPS from Israel, compared to matched pain-free control individuals.

Notably, two species — Dialister succinatiphilus and Phascolarctobacterium faecium – were enriched in patients with CRPS, while three species — Ligilactobacillus salivarius, Bifidobacterium dentium, and Bifidobacterium adolescentis – were increased in control samples, according to their report published last month in Anesthesiology.

“Importantly,” these findings were replicated in an independent cohort of patients with CRPS from Canada, “suggesting that the observed microbiome signature is robust and consistent across different environments,” Minerbi told GI & Hepatology News.

 

Causal Role? 

“These findings collectively suggest a causal role for the gut microbiome in at least some chronic pain conditions,” Minerbi said.

However, the co-authors of a linked editorial cautioned that it’s “unclear if D succinatiphilus or P faecium are functionally relevant to CRPS pathophysiology or if the bacteria increased in healthy control samples protect against CRPS development.”

Minerbi and colleagues also observed that fecal concentrations of all measured short chain fatty acids (SCFA) in patients with CRPS were lower on average compared to pain-free control individuals, of which butyric, hexanoic, and valeric acid showed significant depletion.

Additionally, plasma concentrations of acetic acid showed significant depletion in patients with CRPS vs control individuals, while propionate, butyrate, isobutyrate and 2-methyl-butyric acid showed a trend toward lower concentrations.

The quantification of SCFA in patient stool and serum is a “notable advance” in this study, Zulmary Manjarres, PhD; Ashley Plumb, PhD; and Katelyn Sadler, PhD; with the Center for Advanced Pain Studies at The University of Texas at Dallas, wrote in their editorial.

SCFA are produced by bacteria as a byproduct of dietary fiber fermentation and appropriate levels of these compounds are important to maintain low levels of inflammation in the colon and overall gut health, they explained.

This begs the question of whether administering probiotic bacteria — many of which are believed to exert health benefits through SCFA production — can be used to treat CRPS-associated pain. It’s something that needs to be studied, the editorialists wrote.

Yet, in their view, the “most notable achievement” of Minerbi and colleagues is the development of a machine learning model that accurately, specifically and sensitively categorized individuals as patients with CRPS or control individuals based on their fecal microbiome signature.

The model, trained on exact sequence variant data from the Israeli patients, achieved 89.5% accuracy, 90.0% sensitivity, and 88.9% specificity in distinguishing patients with CRPS from control individuals in the Canadian cohort.

Interestingly, in three patients with CRPS who underwent limb amputation and recovered from their pain, their gut microbiome signature remained unchanged, suggesting that microbiome alterations might precede or persist beyond symptomatic phases.

 

Test and Treat: Are We There Yet? 

The gut microbiome link to chronic pain syndromes is a hot area of research, but for now gut microbial testing followed by treatment aimed at “fixing” the microbiome remains largely experimental.

At this point, comprehensive gut-microbiome sequencing is not a routine, guideline-supported part of care for fibromyalgia or any chronic pain condition.

“Unfortunately, even for doctors interested in this area, we are not quite at the state of being able to diagnose and treat pain syndrome based on microbiome data,” Bonakdar told GI & Hepatology News.

He said there are many reasons for this including that this type of microbiome analysis is not commonly available at a routine lab. If patients do obtain testing, then the results are quite complex and may not translate to a diagnosis or a simple microbiome intervention.

“I think the closest option we have now is considering supplementing with commonly beneficial probiotic in pain conditions,” Bonakdar said.

One example is a preliminary fibromyalgia trial which found that supplementing with Lactobacillus, Bifidobacterium, and Saccharomyces boulardii appeared to have benefit.

“Unfortunately, this is hit or miss as other trials such as one in low back pain did not find benefit,” Bonakdar said.

Addressing gut microbiome changes will become “more actionable when microbiome analysis is more commonplace as well as is the ability to tailor treatment to the abnormalities seen on testing in a real-world manner,” Bonakdar said.

“Until then, there is no harm in promoting an anti-inflammatory diet for our patients with pain which we know can improve components of the microbiome while also supporting pain management,” he concluded.

Minerbi, Bonakdar, and the editorial writers had no relevant disclosures.

A version of this article appeared on Medscape.com.

Dear Friends,

Like many readers, I just returned from Digestive Disease Week® (DDW) in San Diego, California. For the first time in my early career, my experience was not just overwhelming and exhausting. Before, I wanted to do everything – lectures, posters, meetings with friends, prospective research collaborators, and more! This year, I acknowledged that instead of spreading myself thin and not fully engaging, I made a focused daily schedule mixed with productivity and social events, selecting only what was most important to me at this time in my career. This time, after DDW, instead of giving in to my inner introvert and holing myself in my house for a week to recover, I am invigorated by what I learned and the people I met. I can’t wait to see what’s to come next year!

In this issue’s “In Focus”, Dr. Evan Dellon describes his diagnostic approach, including a clear history, endoscopic evaluation with biopsy, and ruling out other causes of esophageal eosinophilia. He emphasizes that treatment should target both inflammation and fibrostenosis and reviews the guidelines and evidence behind first-line treatments, surveillance, and long-term maintenance.

In the second of a two-part series in the “Short Clinical Review” section, Dr. Christopher Vélez, Dr. Rosa L. Yu, and Dr. Jennifer Dimino discuss care for patients with disorders of brain-gut interaction from historically marginalized communities. They highlight ways to improve care for these patients in day-to-day clinical practice.

The transition from trainee to a practicing gastroenterologist may bring with it responsibilities of giving feedback to trainees and/or colleagues to improve. In the “Early Career” section, Dr. Michelle Baliss and Dr. Christine Hachem give practical tips on how best to deliver feedback, with a focus on creating time, building rapport, bidirectional communication, and more.

Lastly, in the “Finance/Legal” section, John S. Gardner, a financial advisor, guides trainees and early career gastroenterologists through estate planning – why it’s important, how to do it effectively, and long-term benefits to starting early.

If you are interested in contributing or have ideas for future TNG topics, please contact me (tjudy@wustl.edu) or Danielle Kiefer (dkiefer@gastro.org), Communications/Managing Editor of TNG.

Until next time, I leave you with a historical fun fact because we would not be where we are now without appreciating where we were: the first case of eosinophilic esophagitis was only first described in 1978 and became a distinct entity in the early 1990s.

Yours truly, 

Judy A. Trieu, MD, MPH

Editor-in-Chief

Assistant Professor of Medicine

Interventional Endoscopy, Division of Gastroenterology

Washington University School of Medicine in St. Louis

Dear Friends,

Like many readers, I just returned from Digestive Disease Week® (DDW) in San Diego, California. For the first time in my early career, my experience was not just overwhelming and exhausting. Before, I wanted to do everything – lectures, posters, meetings with friends, prospective research collaborators, and more! This year, I acknowledged that instead of spreading myself thin and not fully engaging, I made a focused daily schedule mixed with productivity and social events, selecting only what was most important to me at this time in my career. This time, after DDW, instead of giving in to my inner introvert and holing myself in my house for a week to recover, I am invigorated by what I learned and the people I met. I can’t wait to see what’s to come next year!

In this issue’s “In Focus”, Dr. Evan Dellon describes his diagnostic approach, including a clear history, endoscopic evaluation with biopsy, and ruling out other causes of esophageal eosinophilia. He emphasizes that treatment should target both inflammation and fibrostenosis and reviews the guidelines and evidence behind first-line treatments, surveillance, and long-term maintenance.

In the second of a two-part series in the “Short Clinical Review” section, Dr. Christopher Vélez, Dr. Rosa L. Yu, and Dr. Jennifer Dimino discuss care for patients with disorders of brain-gut interaction from historically marginalized communities. They highlight ways to improve care for these patients in day-to-day clinical practice.

The transition from trainee to a practicing gastroenterologist may bring with it responsibilities of giving feedback to trainees and/or colleagues to improve. In the “Early Career” section, Dr. Michelle Baliss and Dr. Christine Hachem give practical tips on how best to deliver feedback, with a focus on creating time, building rapport, bidirectional communication, and more.

Lastly, in the “Finance/Legal” section, John S. Gardner, a financial advisor, guides trainees and early career gastroenterologists through estate planning – why it’s important, how to do it effectively, and long-term benefits to starting early.

If you are interested in contributing or have ideas for future TNG topics, please contact me (tjudy@wustl.edu) or Danielle Kiefer (dkiefer@gastro.org), Communications/Managing Editor of TNG.

Until next time, I leave you with a historical fun fact because we would not be where we are now without appreciating where we were: the first case of eosinophilic esophagitis was only first described in 1978 and became a distinct entity in the early 1990s.

Yours truly, 

Judy A. Trieu, MD, MPH

Editor-in-Chief

Assistant Professor of Medicine

Interventional Endoscopy, Division of Gastroenterology

Washington University School of Medicine in St. Louis

Dear Friends,

Like many readers, I just returned from Digestive Disease Week® (DDW) in San Diego, California. For the first time in my early career, my experience was not just overwhelming and exhausting. Before, I wanted to do everything – lectures, posters, meetings with friends, prospective research collaborators, and more! This year, I acknowledged that instead of spreading myself thin and not fully engaging, I made a focused daily schedule mixed with productivity and social events, selecting only what was most important to me at this time in my career. This time, after DDW, instead of giving in to my inner introvert and holing myself in my house for a week to recover, I am invigorated by what I learned and the people I met. I can’t wait to see what’s to come next year!

In this issue’s “In Focus”, Dr. Evan Dellon describes his diagnostic approach, including a clear history, endoscopic evaluation with biopsy, and ruling out other causes of esophageal eosinophilia. He emphasizes that treatment should target both inflammation and fibrostenosis and reviews the guidelines and evidence behind first-line treatments, surveillance, and long-term maintenance.

In the second of a two-part series in the “Short Clinical Review” section, Dr. Christopher Vélez, Dr. Rosa L. Yu, and Dr. Jennifer Dimino discuss care for patients with disorders of brain-gut interaction from historically marginalized communities. They highlight ways to improve care for these patients in day-to-day clinical practice.

The transition from trainee to a practicing gastroenterologist may bring with it responsibilities of giving feedback to trainees and/or colleagues to improve. In the “Early Career” section, Dr. Michelle Baliss and Dr. Christine Hachem give practical tips on how best to deliver feedback, with a focus on creating time, building rapport, bidirectional communication, and more.

Lastly, in the “Finance/Legal” section, John S. Gardner, a financial advisor, guides trainees and early career gastroenterologists through estate planning – why it’s important, how to do it effectively, and long-term benefits to starting early.

If you are interested in contributing or have ideas for future TNG topics, please contact me (tjudy@wustl.edu) or Danielle Kiefer (dkiefer@gastro.org), Communications/Managing Editor of TNG.

Until next time, I leave you with a historical fun fact because we would not be where we are now without appreciating where we were: the first case of eosinophilic esophagitis was only first described in 1978 and became a distinct entity in the early 1990s.

Yours truly, 

Judy A. Trieu, MD, MPH

Editor-in-Chief

Assistant Professor of Medicine

Interventional Endoscopy, Division of Gastroenterology

Washington University School of Medicine in St. Louis

Below are some selections from what I am reading in the AGA journals, highlighting clinically applicable and possibly practice-changing expert reviews and studies.

Esophagus/Motility

Carlson DA, et al. A Standardized Approach to Performing and Interpreting Functional Lumen Imaging Probe Panometry for Esophageal Motility Disorders: The Dallas Consensus. Gastroenterology. 2025 Feb. doi: 10.1053/j.gastro.2025.01.234.

Parkman HP, et al; NIDDK Gastroparesis Clinical Research Consortium. Characterization of Patients with Symptoms of Gastroparesis Having Frequent Emergency Department Visits and Hospitalizations. Clin Gastroenterol Hepatol. 2025 Apr. doi: 10.1016/j.cgh.2025.01.033.

Dellon ES, et al. Long-term Safety and Efficacy of Budesonide Oral Suspension for Eosinophilic Esophagitis: A 4-Year, Phase 3, Open-Label Study. Clin Gastroenterol Hepatol. 2025 Feb. doi: 10.1016/j.cgh.2024.12.024.

Small Bowel

Hård Af Segerstad EM, et al; TEDDY Study Group. Early Dietary Fiber Intake Reduces Celiac Disease Risk in Genetically Prone Children: Insights From the TEDDY Study. Gastroenterology. 2025 Feb. doi: 10.1053/j.gastro.2025.01.241.

Colon

Shaukat A, et al. AGA Clinical Practice Update on Current Role of Blood Tests for Colorectal Cancer Screening: Commentary. Clin Gastroenterol Hepatol. 2025 Apr. doi: 10.1016/j.cgh.2025.04.003.

Bergman D, et al. Cholecystectomy is a Risk Factor for Microscopic Colitis: A Nationwide Population-based Matched Case Control Study. Clin Gastroenterol Hepatol. 2025 Mar. doi: 10.1016/j.cgh.2024.12.032.

Inflammatory Bowel Disease

Ben-Horin S, et al; Israeli IBD Research Nucleus (IIRN). Capsule Endoscopy-Guided Proactive Treat-to-Target Versus Continued Standard Care in Patients With Quiescent Crohn’s Disease: A Randomized Controlled Trial. Gastroenterology. 2025 Mar. doi: 10.1053/j.gastro.2025.02.031.

Pancreas

Guilabert L, et al; ERICA Consortium. Impact of Fluid Therapy in the Emergency Department in Acute Pancreatitis: a posthoc analysis of the WATERFALL Trial. Clin Gastroenterol Hepatol. 2025 Apr. doi: 10.1016/j.cgh.2025.01.038.

Hepatology

Rhee H, et al. Noncontrast Magnetic Resonance Imaging vs Ultrasonography for Hepatocellular Carcinoma Surveillance: A Randomized, Single-Center Trial. Gastroenterology. 2025 Jan. doi: 10.1053/j.gastro.2024.12.035.

Kronsten VT, et al. Hepatic Encephalopathy: When Lactulose and Rifaximin Are Not Working. Gastroenterology. 2025 Jan. doi: 10.1053/j.gastro.2025.01.010.

Edelson JC, et al. Accuracy and Safety of Endoscopic Ultrasound–Guided Liver Biopsy in Patients with Metabolic Dysfunction–Associated Liver Disease. Tech Innov Gastrointest Endosc. 2025 Apr. doi: 10.1016/j.tige.2025.250918.

Miscellaneous

Martin J, et al. Practical and Impactful Tips for Private Industry Collaborations with Gastroenterology Practices. Clin Gastroenterol Hepatol. 2025 Mar. doi: 10.1016/j.cgh.2025.01.021.

Tejada, Natalia et al. Glucagon-like Peptide-1 Receptor Agonists Are Not Associated With Increased Incidence of Pneumonia After Endoscopic Procedures. Tech Innov Gastrointest Endosc. 2025 Apr. doi: 10.1016/j.tige.2025.250925.

Lazaridis KN, et al. Microplastics and Nanoplastics and the Digestive System. Gastro Hep Adv. 2025 May. doi: 10.1016/j.gastha.2025.100694.

Dr. Trieu is assistant professor of medicine, interventional endoscopy, in the Division of Gastroenterology at Washington University in St. Louis School of Medicine, Missouri.

Below are some selections from what I am reading in the AGA journals, highlighting clinically applicable and possibly practice-changing expert reviews and studies.

Esophagus/Motility

Carlson DA, et al. A Standardized Approach to Performing and Interpreting Functional Lumen Imaging Probe Panometry for Esophageal Motility Disorders: The Dallas Consensus. Gastroenterology. 2025 Feb. doi: 10.1053/j.gastro.2025.01.234.

Parkman HP, et al; NIDDK Gastroparesis Clinical Research Consortium. Characterization of Patients with Symptoms of Gastroparesis Having Frequent Emergency Department Visits and Hospitalizations. Clin Gastroenterol Hepatol. 2025 Apr. doi: 10.1016/j.cgh.2025.01.033.

Dellon ES, et al. Long-term Safety and Efficacy of Budesonide Oral Suspension for Eosinophilic Esophagitis: A 4-Year, Phase 3, Open-Label Study. Clin Gastroenterol Hepatol. 2025 Feb. doi: 10.1016/j.cgh.2024.12.024.

Small Bowel

Hård Af Segerstad EM, et al; TEDDY Study Group. Early Dietary Fiber Intake Reduces Celiac Disease Risk in Genetically Prone Children: Insights From the TEDDY Study. Gastroenterology. 2025 Feb. doi: 10.1053/j.gastro.2025.01.241.

Colon

Shaukat A, et al. AGA Clinical Practice Update on Current Role of Blood Tests for Colorectal Cancer Screening: Commentary. Clin Gastroenterol Hepatol. 2025 Apr. doi: 10.1016/j.cgh.2025.04.003.

Bergman D, et al. Cholecystectomy is a Risk Factor for Microscopic Colitis: A Nationwide Population-based Matched Case Control Study. Clin Gastroenterol Hepatol. 2025 Mar. doi: 10.1016/j.cgh.2024.12.032.

Inflammatory Bowel Disease

Ben-Horin S, et al; Israeli IBD Research Nucleus (IIRN). Capsule Endoscopy-Guided Proactive Treat-to-Target Versus Continued Standard Care in Patients With Quiescent Crohn’s Disease: A Randomized Controlled Trial. Gastroenterology. 2025 Mar. doi: 10.1053/j.gastro.2025.02.031.

Pancreas

Guilabert L, et al; ERICA Consortium. Impact of Fluid Therapy in the Emergency Department in Acute Pancreatitis: a posthoc analysis of the WATERFALL Trial. Clin Gastroenterol Hepatol. 2025 Apr. doi: 10.1016/j.cgh.2025.01.038.

Hepatology

Rhee H, et al. Noncontrast Magnetic Resonance Imaging vs Ultrasonography for Hepatocellular Carcinoma Surveillance: A Randomized, Single-Center Trial. Gastroenterology. 2025 Jan. doi: 10.1053/j.gastro.2024.12.035.

Kronsten VT, et al. Hepatic Encephalopathy: When Lactulose and Rifaximin Are Not Working. Gastroenterology. 2025 Jan. doi: 10.1053/j.gastro.2025.01.010.

Edelson JC, et al. Accuracy and Safety of Endoscopic Ultrasound–Guided Liver Biopsy in Patients with Metabolic Dysfunction–Associated Liver Disease. Tech Innov Gastrointest Endosc. 2025 Apr. doi: 10.1016/j.tige.2025.250918.

Miscellaneous

Martin J, et al. Practical and Impactful Tips for Private Industry Collaborations with Gastroenterology Practices. Clin Gastroenterol Hepatol. 2025 Mar. doi: 10.1016/j.cgh.2025.01.021.

Tejada, Natalia et al. Glucagon-like Peptide-1 Receptor Agonists Are Not Associated With Increased Incidence of Pneumonia After Endoscopic Procedures. Tech Innov Gastrointest Endosc. 2025 Apr. doi: 10.1016/j.tige.2025.250925.

Lazaridis KN, et al. Microplastics and Nanoplastics and the Digestive System. Gastro Hep Adv. 2025 May. doi: 10.1016/j.gastha.2025.100694.

Dr. Trieu is assistant professor of medicine, interventional endoscopy, in the Division of Gastroenterology at Washington University in St. Louis School of Medicine, Missouri.

Below are some selections from what I am reading in the AGA journals, highlighting clinically applicable and possibly practice-changing expert reviews and studies.

Esophagus/Motility

Carlson DA, et al. A Standardized Approach to Performing and Interpreting Functional Lumen Imaging Probe Panometry for Esophageal Motility Disorders: The Dallas Consensus. Gastroenterology. 2025 Feb. doi: 10.1053/j.gastro.2025.01.234.

Parkman HP, et al; NIDDK Gastroparesis Clinical Research Consortium. Characterization of Patients with Symptoms of Gastroparesis Having Frequent Emergency Department Visits and Hospitalizations. Clin Gastroenterol Hepatol. 2025 Apr. doi: 10.1016/j.cgh.2025.01.033.

Dellon ES, et al. Long-term Safety and Efficacy of Budesonide Oral Suspension for Eosinophilic Esophagitis: A 4-Year, Phase 3, Open-Label Study. Clin Gastroenterol Hepatol. 2025 Feb. doi: 10.1016/j.cgh.2024.12.024.

Small Bowel

Hård Af Segerstad EM, et al; TEDDY Study Group. Early Dietary Fiber Intake Reduces Celiac Disease Risk in Genetically Prone Children: Insights From the TEDDY Study. Gastroenterology. 2025 Feb. doi: 10.1053/j.gastro.2025.01.241.

Colon

Shaukat A, et al. AGA Clinical Practice Update on Current Role of Blood Tests for Colorectal Cancer Screening: Commentary. Clin Gastroenterol Hepatol. 2025 Apr. doi: 10.1016/j.cgh.2025.04.003.

Bergman D, et al. Cholecystectomy is a Risk Factor for Microscopic Colitis: A Nationwide Population-based Matched Case Control Study. Clin Gastroenterol Hepatol. 2025 Mar. doi: 10.1016/j.cgh.2024.12.032.

Inflammatory Bowel Disease

Ben-Horin S, et al; Israeli IBD Research Nucleus (IIRN). Capsule Endoscopy-Guided Proactive Treat-to-Target Versus Continued Standard Care in Patients With Quiescent Crohn’s Disease: A Randomized Controlled Trial. Gastroenterology. 2025 Mar. doi: 10.1053/j.gastro.2025.02.031.

Pancreas

Guilabert L, et al; ERICA Consortium. Impact of Fluid Therapy in the Emergency Department in Acute Pancreatitis: a posthoc analysis of the WATERFALL Trial. Clin Gastroenterol Hepatol. 2025 Apr. doi: 10.1016/j.cgh.2025.01.038.

Hepatology

Rhee H, et al. Noncontrast Magnetic Resonance Imaging vs Ultrasonography for Hepatocellular Carcinoma Surveillance: A Randomized, Single-Center Trial. Gastroenterology. 2025 Jan. doi: 10.1053/j.gastro.2024.12.035.

Kronsten VT, et al. Hepatic Encephalopathy: When Lactulose and Rifaximin Are Not Working. Gastroenterology. 2025 Jan. doi: 10.1053/j.gastro.2025.01.010.

Edelson JC, et al. Accuracy and Safety of Endoscopic Ultrasound–Guided Liver Biopsy in Patients with Metabolic Dysfunction–Associated Liver Disease. Tech Innov Gastrointest Endosc. 2025 Apr. doi: 10.1016/j.tige.2025.250918.

Miscellaneous

Martin J, et al. Practical and Impactful Tips for Private Industry Collaborations with Gastroenterology Practices. Clin Gastroenterol Hepatol. 2025 Mar. doi: 10.1016/j.cgh.2025.01.021.

Tejada, Natalia et al. Glucagon-like Peptide-1 Receptor Agonists Are Not Associated With Increased Incidence of Pneumonia After Endoscopic Procedures. Tech Innov Gastrointest Endosc. 2025 Apr. doi: 10.1016/j.tige.2025.250925.

Lazaridis KN, et al. Microplastics and Nanoplastics and the Digestive System. Gastro Hep Adv. 2025 May. doi: 10.1016/j.gastha.2025.100694.

Dr. Trieu is assistant professor of medicine, interventional endoscopy, in the Division of Gastroenterology at Washington University in St. Louis School of Medicine, Missouri.

Feedback is the purposeful practice of offering constructive, goal-directed input rooted in the power of observation and behavioral assessment. Healthcare inherently fosters a broad range of interactions among people with unique insights, and feedback can naturally emerge from this milieu. In medical training, feedback is an indispensable element that personalizes the learning process and drives the professional development of physicians through all career stages.

If delivered effectively, feedback can strengthen the relationship between the evaluator and recipient, promote self-reflection, and enhance motivation. As such, it has the potential to impact us and those we serve for a lifetime. Feedback has been invaluable to our growth as clinicians and has been embedded into our roles as educators. However, delivering effective feedback requires preparation and consideration of potential challenges. Here, we provide some “tried and true” practical tips on delivering feedback to trainees and co-workers and on navigating potential barriers based on lessons learned.

 

Barriers to Effective Feedback

• Time: Feedback is predicated on observation over time and consideration of repetitive processes rather than isolated events. Perhaps the most challenging factor faced by both parties is that of time constraints, leading to limited ability to engage and build rapport.
• Fear: Hesitancy by evaluators to provide feedback in fear of negative impacts on the recipient’s morale or rapport can lead them to shy away from personalized corrective feedback strategies and choose to rely on written evaluations or generic advice.
• Varying approaches: Feedback strategies have evolved from unidirectional, critique-based, hierarchical practices that emphasize the evaluator’s skills to models that prioritize the recipient’s goals and participation (see Table 1). Traditionally employed feedback models such as the “Feedback Sandwich” or the “Pendleton Rules” are criticized because of a lack of proven benefit on performance, recipient goal prioritization, and open communication.^1,2 Studies showing incongruent perceptions of feedback adequacy between trainees and faculty further support the need for recipient-focused strategies.³ Recognition of the foundational role of the reciprocal learner-teacher alliance in feedback integration inspired newer feedback models, such as the “R2C2” and the “Self-Assessment, Feedback, Encouragement, Direction.”^4,5

But which way is best? With increasing abundance and complexity of feedback frameworks, selecting an approach can feel overwhelming and impractical. A generic “one-size-fits-all” strategy or avoidance of feedback altogether can be detrimental. Structured feedback models can also lead to rigid, inauthentic interactions. Below, we suggest a more practical approach through our tips that unifies the common themes of various feedback models and embeds them into daily practice habits while leaving room for personalization.

 

Our Practical Feedback Tips

Tip 1: Set the scene: Create a positive feedback culture

Proactively creating a culture in which feedback is embedded and encouraged is perhaps the most important step. Priming both parties for feedback clarifies intent, increases receptiveness, and paves the way for growth and open communication. It also prevents the misinterpretation of unexpected feedback as an expression of disapproval. To do this, start by regularly stating your intentions at the start of every experience. Explicitly expressing your vision for mutual learning, bidirectional feedback, and growth in your respective roles attaches a positive intention to feedback. Providing a reminder that we are all works in progress and acknowledging this on a regular basis sets the stage for structured growth opportunities.

Scheduling future feedback encounters from the start maintains accountability and prevents feedback from being perceived as the consequence of a particular behavior. The number and timing of feedback sessions can be customized to the duration of the working relationship, generally allowing enough time for a second interaction (at the end of each week, halfway point, etc.).

 

Tip 2: Build rapport

Increasing clinical workloads and pressure to teach in time-constrained settings often results in insufficient time to engage in conversation and trust building. However, a foundational relationship is an essential precursor to meaningful feedback. Ramani et al. state that “relationships, not recipes, are more likely to promote feedback that has an impact on learner performance and ultimately patient care.”⁶ Building this rapport can begin by dedicating a few minutes (before/during rounds, between cases) to exchange information about career interests, hobbies, favorite restaurants, etc. This “small talk” is the beginning of a two-way exchange that ultimately develops into more meaningful exchanges.

In our experience, this simple step is impactful and fulfilling to both parties. This is also a good time for shared vulnerability by talking about what you are currently working on or have worked on at their stage to affirm that feedback is a continuous part of professional development and not a reflection of how far they are from competence at a given point in time. 

 

Tip 3: Consider Timing, assess readiness, and preschedule sessions

Lack of attention to timing can hinder feedback acceptance. We suggest adhering to delivering positive feedback publicly and corrective feedback privately (“Praise in public, perfect in private”). This reinforces positive behaviors, increases motivation, and minimizes demoralization. Prolonged delays between the observed behavior and feedback can decrease its relevance. Conversely, delivering feedback too soon after an emotionally charged experience can be perceived as blame. Pre-designated times for feedback can minimize the guesswork and maintain your accountability for giving feedback without inadvertently linking it to one particular behavior. If the recipient does not appear to be in a state to receive feedback at the predesignated time, you can pivot to a “check-in” session to show support and strengthen rapport.

Tip 4: Customize to the learner and set shared goals

Diversity in backgrounds, perspectives, and personalities can impact how people perceive their own performances and experience feedback. Given the profound impact of sociocultural factors on feedback assimilation, maintaining the recipient and their goals at the core of performance evaluations is key to feedback acceptance. 

A. Trainees

We suggest starting by introducing the idea of feedback as a partnership and something you feel privileged to do to help them achieve mutual goals. It helps to ask them to use the first day to get oriented with the experience, general expectations, challenges they expect to encounter, and their feedback goals. Tailoring your feedback to their goals creates a sense of shared purpose which increases motivation. Encouraging them to develop their own strategies allows them to play an active role in their growth. Giving them the opportunity to share their perceived strengths and deficiencies provides you with valuable information regarding their insight and ability to self-evaluate. This can help you predict their readiness for your feedback and to tailor your approach when there is a mismatch. 

Examples:

• Medical student: Start with “What do you think you are doing well?” and “What do you think you need to work on?” Build on their response with encouragement and empathy. This helps make them more deliberate with what they work on because being a medical student can be overwhelming and can feel as though they have everything to work on.
• Resident/Fellow: By this point, trainees usually have an increased awareness of their strengths and deficiencies. Your questions can then be more specific, giving them autonomy over their learning, such as “What are some of the things you are working on that you want me to give you feedback on this week?” This makes them more aware, intentional, and receptive to your feedback because it is framed as something that they sought out.

B. Colleagues/Staff

Unlike the training environment in which feedback is built-in, giving feedback to co-workers requires you to establish a feedback-conducive environment and to develop a more in-depth understanding of coworkers’ personalities. Similar strategies can be applied, such as proactively setting the scene for open communication, scheduling check-ins, demonstrating receptiveness to feedback, and investing in trust-building. 

Longer working relationships allow for strong foundational connections that make feedback less threatening. Personality assessment testing like Myers-Briggs Type Indicator or DiSC Assessment can aid in tailoring feedback to different individuals.^7,8 An analytical thinker may appreciate direct, data-driven feedback. Relationship-oriented individuals might respond better to softer, encouragement-based approaches. Always maintain shared goals at the center of your interactions and consider collaborative opportunities such as quality improvement projects. This can improve your working relationship in a constructive way without casting blame.

 

Tip 5: Work on delivery: Bidirectional communication and body language

Non-verbal cues can have a profound impact on how your feedback is interpreted and on the recipient’s comfort to engage in conversation. Sitting down, making eye contact, nodding, and avoiding closed-off body posture can project support and feel less judgmental. Creating a safe and non-distracted environment with privacy can make them feel valued. Use motivating, respectful language focused on directly observed behaviors rather than personal attributes or second-hand reports.

Remember that focusing on repetitive patterns is likely more helpful than isolated incidents. Validate their hard work and give them a global idea of where they stand before diving into individual behaviors. Encourage their participation and empower them to suggest changes they plan to implement. Conclude by having them summarize their action plan to give them ownership and to verify that your feedback was interpreted as you intended. Thank them for being a part of the process, as it does take a partnership for feedback to be effective. 

 

Tip 6: Be open to feedback 

Demonstrating your willingness to accept and act on feedback reinforces a positive culture where feedback is normalized and valued. After an unintended outcome, initiate a two-way conversation and ask their input on anything they wish you would have done differently. This reaffirms your commitment to maintaining culture that does not revolve around one-sided critiques. Frequently soliciting feedback about your feedback skills can also guide you to adapt your approach and to recognize any ineffective feedback practices.

Tip 7: When things don’t go as planned

Receiving feedback, no matter how thoughtfully it is delivered, can be an emotionally-charged experience ending in hurt feelings. This happens because of misinterpretation of feedback as an indicator of inadequacy, heightened awareness of underlying insecurities, sociocultural or personal circumstances, frustration with oneself, needing additional guidance, or being caught off-guard by the assessment.

The evaluator should always acknowledge the recipient’s feelings, show compassion, and allow time for processing. When they are ready to talk, it is important to help reframe the recipients’ mindsets to recognize that feedback is not personal or defining and is not a “one and done” reflection of whether they have “made it.” Instead, it is a continual process that we benefit from through all career stages. Again, shared vulnerability can help to normalize feedback and maintain open dialogue. Setting an opportunity for a future check-in can reinforce support and lead to a more productive conversation after they have had time to process. 

 

Conclusion

Effective feedback delivery is an invaluable skill that can result in meaningful goal-directed changes while strengthening professional relationships. Given the complexity of feedback interactions and the many factors that influence its acceptance, no single approach is suitable for all recipients and frequent adaptation of the approach is essential.

In our experience, adhering to these general overarching feedback principles (see Figure 1) has allowed us to have more successful interactions with trainees and colleagues.

Dr. Baliss is based in the Division of Gastroenterology, Washington University in St. Louis, Missouri. Dr. Hachem is director of the Division of Gastroenterology and Digestive Health at Intermountain Medical, Sandy, Utah. Both authors declare no conflicts of interest.

References

1. Parkes J, et al. Feedback sandwiches affect perceptions but not performance. Adv Health Sci Educ Theory Pract. 2013 Aug. doi:10.1007/s10459-012-9377-9.

2. van de Ridder JMM and Wijnen-Meijer M. Pendleton’s Rules: A Mini Review of a Feedback Method. Am J Biomed Sci & Res. 2023 May. doi: 10.34297/AJBSR.2023.19.002542.

3. Sender Liberman A, et al. Surgery residents and attending surgeons have different perceptions of feedback. Med Teach. 2005 Aug. doi: 10.1080/0142590500129183.

4. Sargeant J, et al. R2C2 in Action: Testing an Evidence-Based Model to Facilitate Feedback and Coaching in Residency. J Grad Med Educ. 2017 Apr. doi: 10.4300/JGME-D-16-00398.1.

5. Liakos W, et al. Frameworks for Effective Feedback in Health Professions Education. Acad Med. 2023 May. doi: 10.1097/ACM.0000000000004884.

6. Ramani S, et al. Feedback Redefined: Principles and Practice. J Gen Intern Med. 2019 May. doi: 10.1007/s11606-019-04874-2.

7. Woods RA and Hill PB. Myers-Briggs Type Indicator. StatPearls. StatPearls Publishing. 2022 Sept. https://www.ncbi.nlm.nih.gov/books/NBK554596/

8. Slowikowski MK. Using the DISC behavioral instrument to guide leadership and communication. AORN J. 2005 Nov. doi: 10.1016/s0001-2092(06)60276-7.

Feedback is the purposeful practice of offering constructive, goal-directed input rooted in the power of observation and behavioral assessment. Healthcare inherently fosters a broad range of interactions among people with unique insights, and feedback can naturally emerge from this milieu. In medical training, feedback is an indispensable element that personalizes the learning process and drives the professional development of physicians through all career stages.

If delivered effectively, feedback can strengthen the relationship between the evaluator and recipient, promote self-reflection, and enhance motivation. As such, it has the potential to impact us and those we serve for a lifetime. Feedback has been invaluable to our growth as clinicians and has been embedded into our roles as educators. However, delivering effective feedback requires preparation and consideration of potential challenges. Here, we provide some “tried and true” practical tips on delivering feedback to trainees and co-workers and on navigating potential barriers based on lessons learned.

 

Barriers to Effective Feedback

• Time: Feedback is predicated on observation over time and consideration of repetitive processes rather than isolated events. Perhaps the most challenging factor faced by both parties is that of time constraints, leading to limited ability to engage and build rapport.
• Fear: Hesitancy by evaluators to provide feedback in fear of negative impacts on the recipient’s morale or rapport can lead them to shy away from personalized corrective feedback strategies and choose to rely on written evaluations or generic advice.
• Varying approaches: Feedback strategies have evolved from unidirectional, critique-based, hierarchical practices that emphasize the evaluator’s skills to models that prioritize the recipient’s goals and participation (see Table 1). Traditionally employed feedback models such as the “Feedback Sandwich” or the “Pendleton Rules” are criticized because of a lack of proven benefit on performance, recipient goal prioritization, and open communication.^1,2 Studies showing incongruent perceptions of feedback adequacy between trainees and faculty further support the need for recipient-focused strategies.³ Recognition of the foundational role of the reciprocal learner-teacher alliance in feedback integration inspired newer feedback models, such as the “R2C2” and the “Self-Assessment, Feedback, Encouragement, Direction.”^4,5

But which way is best? With increasing abundance and complexity of feedback frameworks, selecting an approach can feel overwhelming and impractical. A generic “one-size-fits-all” strategy or avoidance of feedback altogether can be detrimental. Structured feedback models can also lead to rigid, inauthentic interactions. Below, we suggest a more practical approach through our tips that unifies the common themes of various feedback models and embeds them into daily practice habits while leaving room for personalization.

 

Our Practical Feedback Tips

Tip 1: Set the scene: Create a positive feedback culture

Proactively creating a culture in which feedback is embedded and encouraged is perhaps the most important step. Priming both parties for feedback clarifies intent, increases receptiveness, and paves the way for growth and open communication. It also prevents the misinterpretation of unexpected feedback as an expression of disapproval. To do this, start by regularly stating your intentions at the start of every experience. Explicitly expressing your vision for mutual learning, bidirectional feedback, and growth in your respective roles attaches a positive intention to feedback. Providing a reminder that we are all works in progress and acknowledging this on a regular basis sets the stage for structured growth opportunities.

Scheduling future feedback encounters from the start maintains accountability and prevents feedback from being perceived as the consequence of a particular behavior. The number and timing of feedback sessions can be customized to the duration of the working relationship, generally allowing enough time for a second interaction (at the end of each week, halfway point, etc.).

 

Tip 2: Build rapport

Increasing clinical workloads and pressure to teach in time-constrained settings often results in insufficient time to engage in conversation and trust building. However, a foundational relationship is an essential precursor to meaningful feedback. Ramani et al. state that “relationships, not recipes, are more likely to promote feedback that has an impact on learner performance and ultimately patient care.”⁶ Building this rapport can begin by dedicating a few minutes (before/during rounds, between cases) to exchange information about career interests, hobbies, favorite restaurants, etc. This “small talk” is the beginning of a two-way exchange that ultimately develops into more meaningful exchanges.

In our experience, this simple step is impactful and fulfilling to both parties. This is also a good time for shared vulnerability by talking about what you are currently working on or have worked on at their stage to affirm that feedback is a continuous part of professional development and not a reflection of how far they are from competence at a given point in time. 

 

Tip 3: Consider Timing, assess readiness, and preschedule sessions

Lack of attention to timing can hinder feedback acceptance. We suggest adhering to delivering positive feedback publicly and corrective feedback privately (“Praise in public, perfect in private”). This reinforces positive behaviors, increases motivation, and minimizes demoralization. Prolonged delays between the observed behavior and feedback can decrease its relevance. Conversely, delivering feedback too soon after an emotionally charged experience can be perceived as blame. Pre-designated times for feedback can minimize the guesswork and maintain your accountability for giving feedback without inadvertently linking it to one particular behavior. If the recipient does not appear to be in a state to receive feedback at the predesignated time, you can pivot to a “check-in” session to show support and strengthen rapport.

Tip 4: Customize to the learner and set shared goals

Diversity in backgrounds, perspectives, and personalities can impact how people perceive their own performances and experience feedback. Given the profound impact of sociocultural factors on feedback assimilation, maintaining the recipient and their goals at the core of performance evaluations is key to feedback acceptance. 

A. Trainees

We suggest starting by introducing the idea of feedback as a partnership and something you feel privileged to do to help them achieve mutual goals. It helps to ask them to use the first day to get oriented with the experience, general expectations, challenges they expect to encounter, and their feedback goals. Tailoring your feedback to their goals creates a sense of shared purpose which increases motivation. Encouraging them to develop their own strategies allows them to play an active role in their growth. Giving them the opportunity to share their perceived strengths and deficiencies provides you with valuable information regarding their insight and ability to self-evaluate. This can help you predict their readiness for your feedback and to tailor your approach when there is a mismatch. 

Examples:

• Medical student: Start with “What do you think you are doing well?” and “What do you think you need to work on?” Build on their response with encouragement and empathy. This helps make them more deliberate with what they work on because being a medical student can be overwhelming and can feel as though they have everything to work on.
• Resident/Fellow: By this point, trainees usually have an increased awareness of their strengths and deficiencies. Your questions can then be more specific, giving them autonomy over their learning, such as “What are some of the things you are working on that you want me to give you feedback on this week?” This makes them more aware, intentional, and receptive to your feedback because it is framed as something that they sought out.

B. Colleagues/Staff

Unlike the training environment in which feedback is built-in, giving feedback to co-workers requires you to establish a feedback-conducive environment and to develop a more in-depth understanding of coworkers’ personalities. Similar strategies can be applied, such as proactively setting the scene for open communication, scheduling check-ins, demonstrating receptiveness to feedback, and investing in trust-building. 

Longer working relationships allow for strong foundational connections that make feedback less threatening. Personality assessment testing like Myers-Briggs Type Indicator or DiSC Assessment can aid in tailoring feedback to different individuals.^7,8 An analytical thinker may appreciate direct, data-driven feedback. Relationship-oriented individuals might respond better to softer, encouragement-based approaches. Always maintain shared goals at the center of your interactions and consider collaborative opportunities such as quality improvement projects. This can improve your working relationship in a constructive way without casting blame.

 

Tip 5: Work on delivery: Bidirectional communication and body language

Non-verbal cues can have a profound impact on how your feedback is interpreted and on the recipient’s comfort to engage in conversation. Sitting down, making eye contact, nodding, and avoiding closed-off body posture can project support and feel less judgmental. Creating a safe and non-distracted environment with privacy can make them feel valued. Use motivating, respectful language focused on directly observed behaviors rather than personal attributes or second-hand reports.

Remember that focusing on repetitive patterns is likely more helpful than isolated incidents. Validate their hard work and give them a global idea of where they stand before diving into individual behaviors. Encourage their participation and empower them to suggest changes they plan to implement. Conclude by having them summarize their action plan to give them ownership and to verify that your feedback was interpreted as you intended. Thank them for being a part of the process, as it does take a partnership for feedback to be effective. 

 

Tip 6: Be open to feedback 

Demonstrating your willingness to accept and act on feedback reinforces a positive culture where feedback is normalized and valued. After an unintended outcome, initiate a two-way conversation and ask their input on anything they wish you would have done differently. This reaffirms your commitment to maintaining culture that does not revolve around one-sided critiques. Frequently soliciting feedback about your feedback skills can also guide you to adapt your approach and to recognize any ineffective feedback practices.

Tip 7: When things don’t go as planned

Receiving feedback, no matter how thoughtfully it is delivered, can be an emotionally-charged experience ending in hurt feelings. This happens because of misinterpretation of feedback as an indicator of inadequacy, heightened awareness of underlying insecurities, sociocultural or personal circumstances, frustration with oneself, needing additional guidance, or being caught off-guard by the assessment.

The evaluator should always acknowledge the recipient’s feelings, show compassion, and allow time for processing. When they are ready to talk, it is important to help reframe the recipients’ mindsets to recognize that feedback is not personal or defining and is not a “one and done” reflection of whether they have “made it.” Instead, it is a continual process that we benefit from through all career stages. Again, shared vulnerability can help to normalize feedback and maintain open dialogue. Setting an opportunity for a future check-in can reinforce support and lead to a more productive conversation after they have had time to process. 

 

Conclusion

Effective feedback delivery is an invaluable skill that can result in meaningful goal-directed changes while strengthening professional relationships. Given the complexity of feedback interactions and the many factors that influence its acceptance, no single approach is suitable for all recipients and frequent adaptation of the approach is essential.

In our experience, adhering to these general overarching feedback principles (see Figure 1) has allowed us to have more successful interactions with trainees and colleagues.

Dr. Baliss is based in the Division of Gastroenterology, Washington University in St. Louis, Missouri. Dr. Hachem is director of the Division of Gastroenterology and Digestive Health at Intermountain Medical, Sandy, Utah. Both authors declare no conflicts of interest.

References

1. Parkes J, et al. Feedback sandwiches affect perceptions but not performance. Adv Health Sci Educ Theory Pract. 2013 Aug. doi:10.1007/s10459-012-9377-9.

2. van de Ridder JMM and Wijnen-Meijer M. Pendleton’s Rules: A Mini Review of a Feedback Method. Am J Biomed Sci & Res. 2023 May. doi: 10.34297/AJBSR.2023.19.002542.

3. Sender Liberman A, et al. Surgery residents and attending surgeons have different perceptions of feedback. Med Teach. 2005 Aug. doi: 10.1080/0142590500129183.

4. Sargeant J, et al. R2C2 in Action: Testing an Evidence-Based Model to Facilitate Feedback and Coaching in Residency. J Grad Med Educ. 2017 Apr. doi: 10.4300/JGME-D-16-00398.1.

5. Liakos W, et al. Frameworks for Effective Feedback in Health Professions Education. Acad Med. 2023 May. doi: 10.1097/ACM.0000000000004884.

6. Ramani S, et al. Feedback Redefined: Principles and Practice. J Gen Intern Med. 2019 May. doi: 10.1007/s11606-019-04874-2.

7. Woods RA and Hill PB. Myers-Briggs Type Indicator. StatPearls. StatPearls Publishing. 2022 Sept. https://www.ncbi.nlm.nih.gov/books/NBK554596/

8. Slowikowski MK. Using the DISC behavioral instrument to guide leadership and communication. AORN J. 2005 Nov. doi: 10.1016/s0001-2092(06)60276-7.

Feedback is the purposeful practice of offering constructive, goal-directed input rooted in the power of observation and behavioral assessment. Healthcare inherently fosters a broad range of interactions among people with unique insights, and feedback can naturally emerge from this milieu. In medical training, feedback is an indispensable element that personalizes the learning process and drives the professional development of physicians through all career stages.

If delivered effectively, feedback can strengthen the relationship between the evaluator and recipient, promote self-reflection, and enhance motivation. As such, it has the potential to impact us and those we serve for a lifetime. Feedback has been invaluable to our growth as clinicians and has been embedded into our roles as educators. However, delivering effective feedback requires preparation and consideration of potential challenges. Here, we provide some “tried and true” practical tips on delivering feedback to trainees and co-workers and on navigating potential barriers based on lessons learned.

 

Barriers to Effective Feedback

• Time: Feedback is predicated on observation over time and consideration of repetitive processes rather than isolated events. Perhaps the most challenging factor faced by both parties is that of time constraints, leading to limited ability to engage and build rapport.
• Fear: Hesitancy by evaluators to provide feedback in fear of negative impacts on the recipient’s morale or rapport can lead them to shy away from personalized corrective feedback strategies and choose to rely on written evaluations or generic advice.
• Varying approaches: Feedback strategies have evolved from unidirectional, critique-based, hierarchical practices that emphasize the evaluator’s skills to models that prioritize the recipient’s goals and participation (see Table 1). Traditionally employed feedback models such as the “Feedback Sandwich” or the “Pendleton Rules” are criticized because of a lack of proven benefit on performance, recipient goal prioritization, and open communication.^1,2 Studies showing incongruent perceptions of feedback adequacy between trainees and faculty further support the need for recipient-focused strategies.³ Recognition of the foundational role of the reciprocal learner-teacher alliance in feedback integration inspired newer feedback models, such as the “R2C2” and the “Self-Assessment, Feedback, Encouragement, Direction.”^4,5

But which way is best? With increasing abundance and complexity of feedback frameworks, selecting an approach can feel overwhelming and impractical. A generic “one-size-fits-all” strategy or avoidance of feedback altogether can be detrimental. Structured feedback models can also lead to rigid, inauthentic interactions. Below, we suggest a more practical approach through our tips that unifies the common themes of various feedback models and embeds them into daily practice habits while leaving room for personalization.

 

Our Practical Feedback Tips

Tip 1: Set the scene: Create a positive feedback culture

Proactively creating a culture in which feedback is embedded and encouraged is perhaps the most important step. Priming both parties for feedback clarifies intent, increases receptiveness, and paves the way for growth and open communication. It also prevents the misinterpretation of unexpected feedback as an expression of disapproval. To do this, start by regularly stating your intentions at the start of every experience. Explicitly expressing your vision for mutual learning, bidirectional feedback, and growth in your respective roles attaches a positive intention to feedback. Providing a reminder that we are all works in progress and acknowledging this on a regular basis sets the stage for structured growth opportunities.

Scheduling future feedback encounters from the start maintains accountability and prevents feedback from being perceived as the consequence of a particular behavior. The number and timing of feedback sessions can be customized to the duration of the working relationship, generally allowing enough time for a second interaction (at the end of each week, halfway point, etc.).

 

Tip 2: Build rapport

Increasing clinical workloads and pressure to teach in time-constrained settings often results in insufficient time to engage in conversation and trust building. However, a foundational relationship is an essential precursor to meaningful feedback. Ramani et al. state that “relationships, not recipes, are more likely to promote feedback that has an impact on learner performance and ultimately patient care.”⁶ Building this rapport can begin by dedicating a few minutes (before/during rounds, between cases) to exchange information about career interests, hobbies, favorite restaurants, etc. This “small talk” is the beginning of a two-way exchange that ultimately develops into more meaningful exchanges.

In our experience, this simple step is impactful and fulfilling to both parties. This is also a good time for shared vulnerability by talking about what you are currently working on or have worked on at their stage to affirm that feedback is a continuous part of professional development and not a reflection of how far they are from competence at a given point in time. 

 

Tip 3: Consider Timing, assess readiness, and preschedule sessions

Lack of attention to timing can hinder feedback acceptance. We suggest adhering to delivering positive feedback publicly and corrective feedback privately (“Praise in public, perfect in private”). This reinforces positive behaviors, increases motivation, and minimizes demoralization. Prolonged delays between the observed behavior and feedback can decrease its relevance. Conversely, delivering feedback too soon after an emotionally charged experience can be perceived as blame. Pre-designated times for feedback can minimize the guesswork and maintain your accountability for giving feedback without inadvertently linking it to one particular behavior. If the recipient does not appear to be in a state to receive feedback at the predesignated time, you can pivot to a “check-in” session to show support and strengthen rapport.

Tip 4: Customize to the learner and set shared goals

Diversity in backgrounds, perspectives, and personalities can impact how people perceive their own performances and experience feedback. Given the profound impact of sociocultural factors on feedback assimilation, maintaining the recipient and their goals at the core of performance evaluations is key to feedback acceptance. 

A. Trainees

We suggest starting by introducing the idea of feedback as a partnership and something you feel privileged to do to help them achieve mutual goals. It helps to ask them to use the first day to get oriented with the experience, general expectations, challenges they expect to encounter, and their feedback goals. Tailoring your feedback to their goals creates a sense of shared purpose which increases motivation. Encouraging them to develop their own strategies allows them to play an active role in their growth. Giving them the opportunity to share their perceived strengths and deficiencies provides you with valuable information regarding their insight and ability to self-evaluate. This can help you predict their readiness for your feedback and to tailor your approach when there is a mismatch. 

Examples:

• Medical student: Start with “What do you think you are doing well?” and “What do you think you need to work on?” Build on their response with encouragement and empathy. This helps make them more deliberate with what they work on because being a medical student can be overwhelming and can feel as though they have everything to work on.
• Resident/Fellow: By this point, trainees usually have an increased awareness of their strengths and deficiencies. Your questions can then be more specific, giving them autonomy over their learning, such as “What are some of the things you are working on that you want me to give you feedback on this week?” This makes them more aware, intentional, and receptive to your feedback because it is framed as something that they sought out.

B. Colleagues/Staff

Unlike the training environment in which feedback is built-in, giving feedback to co-workers requires you to establish a feedback-conducive environment and to develop a more in-depth understanding of coworkers’ personalities. Similar strategies can be applied, such as proactively setting the scene for open communication, scheduling check-ins, demonstrating receptiveness to feedback, and investing in trust-building. 

Longer working relationships allow for strong foundational connections that make feedback less threatening. Personality assessment testing like Myers-Briggs Type Indicator or DiSC Assessment can aid in tailoring feedback to different individuals.^7,8 An analytical thinker may appreciate direct, data-driven feedback. Relationship-oriented individuals might respond better to softer, encouragement-based approaches. Always maintain shared goals at the center of your interactions and consider collaborative opportunities such as quality improvement projects. This can improve your working relationship in a constructive way without casting blame.

 

Tip 5: Work on delivery: Bidirectional communication and body language

Non-verbal cues can have a profound impact on how your feedback is interpreted and on the recipient’s comfort to engage in conversation. Sitting down, making eye contact, nodding, and avoiding closed-off body posture can project support and feel less judgmental. Creating a safe and non-distracted environment with privacy can make them feel valued. Use motivating, respectful language focused on directly observed behaviors rather than personal attributes or second-hand reports.

Remember that focusing on repetitive patterns is likely more helpful than isolated incidents. Validate their hard work and give them a global idea of where they stand before diving into individual behaviors. Encourage their participation and empower them to suggest changes they plan to implement. Conclude by having them summarize their action plan to give them ownership and to verify that your feedback was interpreted as you intended. Thank them for being a part of the process, as it does take a partnership for feedback to be effective. 

 

Tip 6: Be open to feedback 

Demonstrating your willingness to accept and act on feedback reinforces a positive culture where feedback is normalized and valued. After an unintended outcome, initiate a two-way conversation and ask their input on anything they wish you would have done differently. This reaffirms your commitment to maintaining culture that does not revolve around one-sided critiques. Frequently soliciting feedback about your feedback skills can also guide you to adapt your approach and to recognize any ineffective feedback practices.

Tip 7: When things don’t go as planned

Receiving feedback, no matter how thoughtfully it is delivered, can be an emotionally-charged experience ending in hurt feelings. This happens because of misinterpretation of feedback as an indicator of inadequacy, heightened awareness of underlying insecurities, sociocultural or personal circumstances, frustration with oneself, needing additional guidance, or being caught off-guard by the assessment.

The evaluator should always acknowledge the recipient’s feelings, show compassion, and allow time for processing. When they are ready to talk, it is important to help reframe the recipients’ mindsets to recognize that feedback is not personal or defining and is not a “one and done” reflection of whether they have “made it.” Instead, it is a continual process that we benefit from through all career stages. Again, shared vulnerability can help to normalize feedback and maintain open dialogue. Setting an opportunity for a future check-in can reinforce support and lead to a more productive conversation after they have had time to process. 

 

Conclusion

Effective feedback delivery is an invaluable skill that can result in meaningful goal-directed changes while strengthening professional relationships. Given the complexity of feedback interactions and the many factors that influence its acceptance, no single approach is suitable for all recipients and frequent adaptation of the approach is essential.

In our experience, adhering to these general overarching feedback principles (see Figure 1) has allowed us to have more successful interactions with trainees and colleagues.

Dr. Baliss is based in the Division of Gastroenterology, Washington University in St. Louis, Missouri. Dr. Hachem is director of the Division of Gastroenterology and Digestive Health at Intermountain Medical, Sandy, Utah. Both authors declare no conflicts of interest.

References

1. Parkes J, et al. Feedback sandwiches affect perceptions but not performance. Adv Health Sci Educ Theory Pract. 2013 Aug. doi:10.1007/s10459-012-9377-9.

2. van de Ridder JMM and Wijnen-Meijer M. Pendleton’s Rules: A Mini Review of a Feedback Method. Am J Biomed Sci & Res. 2023 May. doi: 10.34297/AJBSR.2023.19.002542.

3. Sender Liberman A, et al. Surgery residents and attending surgeons have different perceptions of feedback. Med Teach. 2005 Aug. doi: 10.1080/0142590500129183.

4. Sargeant J, et al. R2C2 in Action: Testing an Evidence-Based Model to Facilitate Feedback and Coaching in Residency. J Grad Med Educ. 2017 Apr. doi: 10.4300/JGME-D-16-00398.1.

5. Liakos W, et al. Frameworks for Effective Feedback in Health Professions Education. Acad Med. 2023 May. doi: 10.1097/ACM.0000000000004884.

6. Ramani S, et al. Feedback Redefined: Principles and Practice. J Gen Intern Med. 2019 May. doi: 10.1007/s11606-019-04874-2.

7. Woods RA and Hill PB. Myers-Briggs Type Indicator. StatPearls. StatPearls Publishing. 2022 Sept. https://www.ncbi.nlm.nih.gov/books/NBK554596/

8. Slowikowski MK. Using the DISC behavioral instrument to guide leadership and communication. AORN J. 2005 Nov. doi: 10.1016/s0001-2092(06)60276-7.

Demand for specialized GI care has skyrocketed in recent years, eclipsing the supply of gastroenterologists and impairing patient access to high-quality GI care, particularly in rural and other underserved areas. In this environment, advanced practice providers (APPs), including nurse practitioners (NPs) and physician assistants (PAs), have become increasingly vital clinical partners to gastroenterologists in optimizing patient access, improving health outcomes, and ensuring continuity of care.

Across specialties, APPs are estimated to constitute roughly a third of the US clinical workforce, and demand is only growing. A June 2024 MGMA Stat poll found that 63% of medical groups planned to add new APP roles in the next year. As the GI APP workforce grows, so too will demand for advanced training tailored to the APP role.

AGA has invested heavily in professional development opportunities for NPs and PAs, in recognition of their vital role in providing high-quality GI care. The newly formed AGA NPPA Task Force, co-chaired by Abigail Meyers (who we featured in GIHN’s April issue) and Kimberly Kearns, works closely with the Education and Training Committee to develop education programs to meet the specific needs of NPs and PAs, and advocate for more APP involvement in AGA programming. One example of this is AGA’s 2025 Principles of GI for the NP and PA course, which will be held in Chicago in early August – I encourage you to spread the word and support your APP colleagues in getting involved in these important initiatives as our vital partners in GI care delivery.

In this month’s issue of GIHN, we present the exciting results of the BOSS trial, showing no survival difference between regular and at need surveillance for Barrett’s esophagus, suggesting that at need endoscopy may be a safe alternative for low-risk patients. Continuing our coverage of potentially practice-changing research from DDW, we highlight another recent RCT challenging the use of papillary sphincterotomy as a treatment for pancreas divisum.

In our July Member Spotlight, Eric Shah, MD, MBA (University of Michigan), a past AGA Research Scholar Award recipient, highlights how this critical research support aided him in his journey to develop a now FDA-approved point-of care screening tool used to evaluate patients with chronic constipation for pelvic floor dysfunction during a routine clinic visit. In our quarterly Perspectives column, Dr. David Wan (a GI hospitalist) and Dr. Zeyed Metwalli (an interventional radiologist) discuss best practices in management of lower GI bleeding. We hope you have a restful summer!

Megan A. Adams, MD, JD, MSc

Editor in Chief

Demand for specialized GI care has skyrocketed in recent years, eclipsing the supply of gastroenterologists and impairing patient access to high-quality GI care, particularly in rural and other underserved areas. In this environment, advanced practice providers (APPs), including nurse practitioners (NPs) and physician assistants (PAs), have become increasingly vital clinical partners to gastroenterologists in optimizing patient access, improving health outcomes, and ensuring continuity of care.

Across specialties, APPs are estimated to constitute roughly a third of the US clinical workforce, and demand is only growing. A June 2024 MGMA Stat poll found that 63% of medical groups planned to add new APP roles in the next year. As the GI APP workforce grows, so too will demand for advanced training tailored to the APP role.

AGA has invested heavily in professional development opportunities for NPs and PAs, in recognition of their vital role in providing high-quality GI care. The newly formed AGA NPPA Task Force, co-chaired by Abigail Meyers (who we featured in GIHN’s April issue) and Kimberly Kearns, works closely with the Education and Training Committee to develop education programs to meet the specific needs of NPs and PAs, and advocate for more APP involvement in AGA programming. One example of this is AGA’s 2025 Principles of GI for the NP and PA course, which will be held in Chicago in early August – I encourage you to spread the word and support your APP colleagues in getting involved in these important initiatives as our vital partners in GI care delivery.

In this month’s issue of GIHN, we present the exciting results of the BOSS trial, showing no survival difference between regular and at need surveillance for Barrett’s esophagus, suggesting that at need endoscopy may be a safe alternative for low-risk patients. Continuing our coverage of potentially practice-changing research from DDW, we highlight another recent RCT challenging the use of papillary sphincterotomy as a treatment for pancreas divisum.

In our July Member Spotlight, Eric Shah, MD, MBA (University of Michigan), a past AGA Research Scholar Award recipient, highlights how this critical research support aided him in his journey to develop a now FDA-approved point-of care screening tool used to evaluate patients with chronic constipation for pelvic floor dysfunction during a routine clinic visit. In our quarterly Perspectives column, Dr. David Wan (a GI hospitalist) and Dr. Zeyed Metwalli (an interventional radiologist) discuss best practices in management of lower GI bleeding. We hope you have a restful summer!

Megan A. Adams, MD, JD, MSc

Editor in Chief

Demand for specialized GI care has skyrocketed in recent years, eclipsing the supply of gastroenterologists and impairing patient access to high-quality GI care, particularly in rural and other underserved areas. In this environment, advanced practice providers (APPs), including nurse practitioners (NPs) and physician assistants (PAs), have become increasingly vital clinical partners to gastroenterologists in optimizing patient access, improving health outcomes, and ensuring continuity of care.

Across specialties, APPs are estimated to constitute roughly a third of the US clinical workforce, and demand is only growing. A June 2024 MGMA Stat poll found that 63% of medical groups planned to add new APP roles in the next year. As the GI APP workforce grows, so too will demand for advanced training tailored to the APP role.

AGA has invested heavily in professional development opportunities for NPs and PAs, in recognition of their vital role in providing high-quality GI care. The newly formed AGA NPPA Task Force, co-chaired by Abigail Meyers (who we featured in GIHN’s April issue) and Kimberly Kearns, works closely with the Education and Training Committee to develop education programs to meet the specific needs of NPs and PAs, and advocate for more APP involvement in AGA programming. One example of this is AGA’s 2025 Principles of GI for the NP and PA course, which will be held in Chicago in early August – I encourage you to spread the word and support your APP colleagues in getting involved in these important initiatives as our vital partners in GI care delivery.

In this month’s issue of GIHN, we present the exciting results of the BOSS trial, showing no survival difference between regular and at need surveillance for Barrett’s esophagus, suggesting that at need endoscopy may be a safe alternative for low-risk patients. Continuing our coverage of potentially practice-changing research from DDW, we highlight another recent RCT challenging the use of papillary sphincterotomy as a treatment for pancreas divisum.

In our July Member Spotlight, Eric Shah, MD, MBA (University of Michigan), a past AGA Research Scholar Award recipient, highlights how this critical research support aided him in his journey to develop a now FDA-approved point-of care screening tool used to evaluate patients with chronic constipation for pelvic floor dysfunction during a routine clinic visit. In our quarterly Perspectives column, Dr. David Wan (a GI hospitalist) and Dr. Zeyed Metwalli (an interventional radiologist) discuss best practices in management of lower GI bleeding. We hope you have a restful summer!

Megan A. Adams, MD, JD, MSc

Editor in Chief

Hepatic encephalopathy (HE) is no longer a rare complication – it’s an urgent clinical reality that’s a leading cause of hospitalization in patients with cirrhosis.¹ HE can be deceptively subtle or profoundly severe, presenting with a wide clinical spectrum – from mild cognitive slowing to life-threatening coma. Without clear disease biomarkers, HE remains a diagnosis of exclusion, making it critical for clinicians to remain vigilant, especially in patients with chronic liver disease (CLD).

The incidence of CLD is climbing, fueled by rising rates of alcohol-associated liver disease, metabolic dysfunction-associated steatotic liver disease (MASLD), and hepatitis C, which is often undiagnosed. For example:

• More than 2 million Americans had alcohol-associated cirrhosis as of 2017.²
• Currently, 38% of all adults and 7–14% of children and adolescents have MASLD. By 2040, the MASLD prevalence rate for adults is projected to increase to more than 55%.³
• The economic burden is staggering – from $1 billion⁴ in 2003 to over $7 billion⁵ in hospital costs for cirrhosis-related admissions today.

These figures aren’t just statistics – they represent a growing population of patients who are at risk of developing HE, sometimes without ever receiving a proper diagnosis or follow-up care.

Because HE mimics many other forms of neurological dysfunction – delirium, alcohol intoxication, diabetes-related confusion – it can be easy to miss or misdiagnose. But differentiating HE from other causes of altered mental status is critical, especially for patients who may ultimately require liver transplantation.^{6, 7}

Moreover, patients frequently leave the hospital without adequate education or maintenance medication for episodic overt HE. Without coordinated follow-up between primary care, hepatology, and caregivers, these patients are at risk for recurrence.

To close these practice gaps, education is key. AGA’s course, “Missing the Mark: Hepatic Encephalopathy,” provides clinicians with up-to-date guidance on:

• The changing epidemiology of cirrhosis and undiagnosed cirrhosis for patients with liver disease.
• Assessment guidelines and best practices for HE diagnosis and management.
• How to develop transition-of-care plans with patients, caretakers, and specialty providers after an initial HE diagnosis.

Take the course today: https://tinyurl.com/3muwhmj5

Don’t wait until HE is an emergency. Equip yourself with the tools to recognize it earlier, treat it effectively, and coordinate better care.

References

1. Wolf, DC. Hepatic Encephalopathy. Medscape. 2020 May 1. Retrieved from: https://emedicine.medscape.com/article/186101-overview

2. Singal AK, Mathurin P. Diagnosis and treatment of alcohol-associated liver disease A review. JAMA. 2021 Jul. doi:10.1001/jama.2021.7683.

3. Younossi ZM, et al. Epidemiology of metabolic dysfunction-associated steatotic liver disease. Clin Mol Hepatol. 2025 Feb. doi: 10.3350/cmh.2024.0431.

4. Vilstrup H, et al. Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver. Hepatology. 2014 Aug. doi: 10.1002/hep.27210.

5. Desai AP, et al. Increasing Economic Burden in Hospitalized Patients With Cirrhosis: Analysis of a National Database. Clin Transl Gastroenterol. 2019 Jul. doi: 10.14309/ctg.0000000000000062.

6. Serper M, et al. Hepatic encephalopathy predicts early post-transplant cognitive and functional impairment: The Livcog cohort study. Hepatol Commun. 2025 Apr. doi: 10.1097/HC9.0000000000000696.

7. Montagnese S, Bajaj JS. Impact of Hepatic Encephalopathy in Cirrhosis on Quality-of-Life Issues. Drugs. 2019 Jan. doi: 10.1007/s40265-018-1019-y.

Hepatic encephalopathy (HE) is no longer a rare complication – it’s an urgent clinical reality that’s a leading cause of hospitalization in patients with cirrhosis.¹ HE can be deceptively subtle or profoundly severe, presenting with a wide clinical spectrum – from mild cognitive slowing to life-threatening coma. Without clear disease biomarkers, HE remains a diagnosis of exclusion, making it critical for clinicians to remain vigilant, especially in patients with chronic liver disease (CLD).

The incidence of CLD is climbing, fueled by rising rates of alcohol-associated liver disease, metabolic dysfunction-associated steatotic liver disease (MASLD), and hepatitis C, which is often undiagnosed. For example:

• More than 2 million Americans had alcohol-associated cirrhosis as of 2017.²
• Currently, 38% of all adults and 7–14% of children and adolescents have MASLD. By 2040, the MASLD prevalence rate for adults is projected to increase to more than 55%.³
• The economic burden is staggering – from $1 billion⁴ in 2003 to over $7 billion⁵ in hospital costs for cirrhosis-related admissions today.

These figures aren’t just statistics – they represent a growing population of patients who are at risk of developing HE, sometimes without ever receiving a proper diagnosis or follow-up care.

Because HE mimics many other forms of neurological dysfunction – delirium, alcohol intoxication, diabetes-related confusion – it can be easy to miss or misdiagnose. But differentiating HE from other causes of altered mental status is critical, especially for patients who may ultimately require liver transplantation.^{6, 7}

Moreover, patients frequently leave the hospital without adequate education or maintenance medication for episodic overt HE. Without coordinated follow-up between primary care, hepatology, and caregivers, these patients are at risk for recurrence.

To close these practice gaps, education is key. AGA’s course, “Missing the Mark: Hepatic Encephalopathy,” provides clinicians with up-to-date guidance on:

• The changing epidemiology of cirrhosis and undiagnosed cirrhosis for patients with liver disease.
• Assessment guidelines and best practices for HE diagnosis and management.
• How to develop transition-of-care plans with patients, caretakers, and specialty providers after an initial HE diagnosis.

Take the course today: https://tinyurl.com/3muwhmj5

Don’t wait until HE is an emergency. Equip yourself with the tools to recognize it earlier, treat it effectively, and coordinate better care.

References

1. Wolf, DC. Hepatic Encephalopathy. Medscape. 2020 May 1. Retrieved from: https://emedicine.medscape.com/article/186101-overview

2. Singal AK, Mathurin P. Diagnosis and treatment of alcohol-associated liver disease A review. JAMA. 2021 Jul. doi:10.1001/jama.2021.7683.

3. Younossi ZM, et al. Epidemiology of metabolic dysfunction-associated steatotic liver disease. Clin Mol Hepatol. 2025 Feb. doi: 10.3350/cmh.2024.0431.

4. Vilstrup H, et al. Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver. Hepatology. 2014 Aug. doi: 10.1002/hep.27210.

5. Desai AP, et al. Increasing Economic Burden in Hospitalized Patients With Cirrhosis: Analysis of a National Database. Clin Transl Gastroenterol. 2019 Jul. doi: 10.14309/ctg.0000000000000062.

6. Serper M, et al. Hepatic encephalopathy predicts early post-transplant cognitive and functional impairment: The Livcog cohort study. Hepatol Commun. 2025 Apr. doi: 10.1097/HC9.0000000000000696.

7. Montagnese S, Bajaj JS. Impact of Hepatic Encephalopathy in Cirrhosis on Quality-of-Life Issues. Drugs. 2019 Jan. doi: 10.1007/s40265-018-1019-y.

Hepatic encephalopathy (HE) is no longer a rare complication – it’s an urgent clinical reality that’s a leading cause of hospitalization in patients with cirrhosis.¹ HE can be deceptively subtle or profoundly severe, presenting with a wide clinical spectrum – from mild cognitive slowing to life-threatening coma. Without clear disease biomarkers, HE remains a diagnosis of exclusion, making it critical for clinicians to remain vigilant, especially in patients with chronic liver disease (CLD).

The incidence of CLD is climbing, fueled by rising rates of alcohol-associated liver disease, metabolic dysfunction-associated steatotic liver disease (MASLD), and hepatitis C, which is often undiagnosed. For example:

• More than 2 million Americans had alcohol-associated cirrhosis as of 2017.²
• Currently, 38% of all adults and 7–14% of children and adolescents have MASLD. By 2040, the MASLD prevalence rate for adults is projected to increase to more than 55%.³
• The economic burden is staggering – from $1 billion⁴ in 2003 to over $7 billion⁵ in hospital costs for cirrhosis-related admissions today.

These figures aren’t just statistics – they represent a growing population of patients who are at risk of developing HE, sometimes without ever receiving a proper diagnosis or follow-up care.

Because HE mimics many other forms of neurological dysfunction – delirium, alcohol intoxication, diabetes-related confusion – it can be easy to miss or misdiagnose. But differentiating HE from other causes of altered mental status is critical, especially for patients who may ultimately require liver transplantation.^{6, 7}

Moreover, patients frequently leave the hospital without adequate education or maintenance medication for episodic overt HE. Without coordinated follow-up between primary care, hepatology, and caregivers, these patients are at risk for recurrence.

To close these practice gaps, education is key. AGA’s course, “Missing the Mark: Hepatic Encephalopathy,” provides clinicians with up-to-date guidance on:

• The changing epidemiology of cirrhosis and undiagnosed cirrhosis for patients with liver disease.
• Assessment guidelines and best practices for HE diagnosis and management.
• How to develop transition-of-care plans with patients, caretakers, and specialty providers after an initial HE diagnosis.

Take the course today: https://tinyurl.com/3muwhmj5

Don’t wait until HE is an emergency. Equip yourself with the tools to recognize it earlier, treat it effectively, and coordinate better care.

References

1. Wolf, DC. Hepatic Encephalopathy. Medscape. 2020 May 1. Retrieved from: https://emedicine.medscape.com/article/186101-overview

2. Singal AK, Mathurin P. Diagnosis and treatment of alcohol-associated liver disease A review. JAMA. 2021 Jul. doi:10.1001/jama.2021.7683.

3. Younossi ZM, et al. Epidemiology of metabolic dysfunction-associated steatotic liver disease. Clin Mol Hepatol. 2025 Feb. doi: 10.3350/cmh.2024.0431.

4. Vilstrup H, et al. Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver. Hepatology. 2014 Aug. doi: 10.1002/hep.27210.

5. Desai AP, et al. Increasing Economic Burden in Hospitalized Patients With Cirrhosis: Analysis of a National Database. Clin Transl Gastroenterol. 2019 Jul. doi: 10.14309/ctg.0000000000000062.

6. Serper M, et al. Hepatic encephalopathy predicts early post-transplant cognitive and functional impairment: The Livcog cohort study. Hepatol Commun. 2025 Apr. doi: 10.1097/HC9.0000000000000696.

7. Montagnese S, Bajaj JS. Impact of Hepatic Encephalopathy in Cirrhosis on Quality-of-Life Issues. Drugs. 2019 Jan. doi: 10.1007/s40265-018-1019-y.

As a physician, you’ve spent years building a career that not only provides financial security for your family but also allows you to make a meaningful impact in your community. However, without a comprehensive estate plan in place, much of what you’ve worked so hard to build may not be preserved according to your wishes.

Many physicians delay estate planning, assuming it’s something to consider later in life. However, the most successful estate plans are those that are established early and evolve over time. Proper planning ensures that your assets are protected, your loved ones are provided for, and your legacy is preserved in the most tax-efficient and legally-sound manner possible.¹

This article explores why estate planning is particularly crucial for physicians, the key elements of a strong estate plan, and how beginning early can create long-term financial advantages.

 

Why Estate Planning Matters for Physicians

Physicians are in a unique financial position compared to many other professionals. With high earning potential, specialized assets, and significant liability exposure, their estate planning needs differ from those of the average individual. A well-structured estate plan not only facilitates the smooth transfer of wealth but also protects assets from excessive taxation, legal complications, and potential risks such as malpractice claims.

1. High Net-Worth Considerations

Physicians often accumulate substantial wealth over time. Without a clear estate plan, your estate could face excessive taxation, with a large portion of your assets potentially going to the government rather than your heirs. Estate taxes, probate costs, and legal fees can significantly erode your legacy if not properly planned for.

2. Asset Protection from Liability Risks

Unlike most professionals, physicians are at a higher risk of litigation. A comprehensive estate plan can incorporate asset protection strategies, such as irrevocable trusts, family limited partnerships, or liability insurance, to shield your wealth from lawsuits or creditor claims.

3. Family and Generational Wealth Planning

Many physicians prioritize ensuring their family’s financial stability. Whether you want to provide for your spouse, children, or even charitable causes, estate planning allows you to dictate how your wealth is distributed. Establishing trusts for your children or grandchildren can help manage how and when they receive their inheritance, preventing mismanagement and ensuring financial responsibility.

4. Business and Practice Continuity

If you own a medical practice, succession planning should be part of your estate plan. Without clear directives, the future of your practice may be uncertain in the event of your passing or incapacitation. A well-drafted estate plan provides a roadmap for ownership transition, ensuring continuity for patients, employees, and business partners.

Key Elements of an Effective Estate Plan

Every estate plan should be customized based on your financial situation, goals, and family dynamics. However, certain fundamental components apply to nearly all high-net-worth individuals, including physicians.

1. Revocable Living Trusts

A revocable living trust allows you to manage your assets during your lifetime while providing a clear path for distribution after your passing. Unlike a will, a trust helps your estate avoid probate, ensuring a smoother and more private transition of wealth. You maintain control over your assets while also establishing clear rules for distribution, particularly useful if you have minor children or complex family structures.²

2. Irrevocable Trusts for Asset Protection

For physicians concerned about lawsuits or estate tax exposure, irrevocable trusts can offer robust asset protection. Since assets placed in these trusts are no longer legally owned by you, they are shielded from creditors and legal claims while also reducing your taxable estate.²

3. Powers of Attorney and Healthcare Directives

Estate planning isn’t just about what happens after your passing—it’s also about protecting you and your family if you become incapacitated. A durable power of attorney allows a trusted individual to manage your financial affairs, while a healthcare directive ensures your medical decisions align with your wishes.³

4. Life Insurance Planning

Life insurance is an essential estate planning tool for physicians, providing liquidity to cover estate taxes, debts, or income replacement for your family. A properly structured life insurance trust can help ensure that policy proceeds remain outside of your taxable estate while being efficiently distributed according to your wishes.⁴

5. Business Succession Planning

If you own a medical practice, a well-designed succession plan can ensure that your business continues to operate smoothly in your absence. This may involve buy-sell agreements, key-person insurance, or identifying a successor to take over your role.⁵

The Long-Term Benefits of Early Estate Planning

Estate planning is not a one-time event—it’s a process that should evolve with your career, financial growth, and family dynamics. The earlier you begin, the more control you have over your financial future. Here’s why starting early is a strategic advantage:

1. Maximizing Tax Efficiency

Many estate planning strategies, such as gifting assets or establishing irrevocable trusts, are most effective when implemented over time. By spreading out wealth transfers and taking advantage of annual gift exclusions, you can significantly reduce estate tax liability while maintaining financial security.

2. Adjusting for Life Changes

Your financial situation and family needs will change over the years. Marriages, births, career advancements, and new investments all impact your estate planning needs. By starting early, you can make gradual adjustments rather than facing an overwhelming restructuring later in life.¹

3. Ensuring Asset Protection Strategies Are in Place

Many asset protection strategies require time to be effective. For instance, certain types of trusts must be in place for a number of years before they fully shield assets from legal claims. Delaying planning could leave your wealth unnecessarily exposed.

4. Creating a Legacy Beyond Wealth

Estate planning is not just about finances—it’s about legacy. Whether you want to support a charitable cause, endow a scholarship, or establish a foundation, early planning gives you the ability to shape your long-term impact.

5. Adapt to Ever Changing Legislation

Estate planning needs to be adaptable. The federal government can change the estate tax exemption at any time; this was even a topic of the last election cycle. Early planning allows you to implement necessary changes throughout your life to minimize estate taxes. At present, unless new policy is enacted, the exemption per individual will reduce by half in 2026 (see Figure 1).

Final Thoughts: Taking Action Today

Estate planning is a powerful tool for physicians looking to protect their wealth, provide for their families, and leave a lasting legacy. The complexity of physician finances—ranging from high income and significant assets to legal risks—makes individualized estate planning an absolute necessity.

By taking proactive steps today, you can maximize tax efficiency, safeguard your assets, and ensure your wishes are carried out without unnecessary delays or legal battles. Working with a financial advisor and estate planning attorney who understands the unique needs of physicians can help you craft a plan that aligns with your goals and evolves as your career progresses.

Mr. Gardner is a financial advisor at Lifetime Financial Growth, LLC, in Columbus, Ohio, one of the largest privately held wealth management firms in the country. John has had a passion for finance since his early years in college when his tennis coach introduced him. He also has a passion for helping physicians, as his wife is a gastroenterologist at Ohio State University. He reports no relevant disclosures relevant to this article. If you have additional questions, please contact John at 740-403-4891 or john_s_gardner@glic.com.

References

1. The Law Offices of Diron Rutty, LLC. https://www.dironruttyllc.com/reasons-to-start-estate-planning-early/. 

2. Physician Side Gigs. https://www.physiciansidegigs.com/estateplanning.

3. Afshar, A & MacBeth, S. https://www.schwabe.com/publication/estate-planning-for-physicians-why-its-important-and-how-to-get-started/. December 2024. 

4. Skeeles, JC. https://ohioline.osu.edu/factsheet/ep-1. July 2012.

5. Rosenfeld, J. Physician estate planning guide. Medical Economics. 2022 Nov. https://www.medicaleconomics.com/view/physician-estate-planning-guide.

As a physician, you’ve spent years building a career that not only provides financial security for your family but also allows you to make a meaningful impact in your community. However, without a comprehensive estate plan in place, much of what you’ve worked so hard to build may not be preserved according to your wishes.

Many physicians delay estate planning, assuming it’s something to consider later in life. However, the most successful estate plans are those that are established early and evolve over time. Proper planning ensures that your assets are protected, your loved ones are provided for, and your legacy is preserved in the most tax-efficient and legally-sound manner possible.¹

This article explores why estate planning is particularly crucial for physicians, the key elements of a strong estate plan, and how beginning early can create long-term financial advantages.

 

Why Estate Planning Matters for Physicians

Physicians are in a unique financial position compared to many other professionals. With high earning potential, specialized assets, and significant liability exposure, their estate planning needs differ from those of the average individual. A well-structured estate plan not only facilitates the smooth transfer of wealth but also protects assets from excessive taxation, legal complications, and potential risks such as malpractice claims.

1. High Net-Worth Considerations

Physicians often accumulate substantial wealth over time. Without a clear estate plan, your estate could face excessive taxation, with a large portion of your assets potentially going to the government rather than your heirs. Estate taxes, probate costs, and legal fees can significantly erode your legacy if not properly planned for.

2. Asset Protection from Liability Risks

Unlike most professionals, physicians are at a higher risk of litigation. A comprehensive estate plan can incorporate asset protection strategies, such as irrevocable trusts, family limited partnerships, or liability insurance, to shield your wealth from lawsuits or creditor claims.

3. Family and Generational Wealth Planning

Many physicians prioritize ensuring their family’s financial stability. Whether you want to provide for your spouse, children, or even charitable causes, estate planning allows you to dictate how your wealth is distributed. Establishing trusts for your children or grandchildren can help manage how and when they receive their inheritance, preventing mismanagement and ensuring financial responsibility.

4. Business and Practice Continuity

If you own a medical practice, succession planning should be part of your estate plan. Without clear directives, the future of your practice may be uncertain in the event of your passing or incapacitation. A well-drafted estate plan provides a roadmap for ownership transition, ensuring continuity for patients, employees, and business partners.

Key Elements of an Effective Estate Plan

Every estate plan should be customized based on your financial situation, goals, and family dynamics. However, certain fundamental components apply to nearly all high-net-worth individuals, including physicians.

1. Revocable Living Trusts

A revocable living trust allows you to manage your assets during your lifetime while providing a clear path for distribution after your passing. Unlike a will, a trust helps your estate avoid probate, ensuring a smoother and more private transition of wealth. You maintain control over your assets while also establishing clear rules for distribution, particularly useful if you have minor children or complex family structures.²

2. Irrevocable Trusts for Asset Protection

For physicians concerned about lawsuits or estate tax exposure, irrevocable trusts can offer robust asset protection. Since assets placed in these trusts are no longer legally owned by you, they are shielded from creditors and legal claims while also reducing your taxable estate.²

3. Powers of Attorney and Healthcare Directives

Estate planning isn’t just about what happens after your passing—it’s also about protecting you and your family if you become incapacitated. A durable power of attorney allows a trusted individual to manage your financial affairs, while a healthcare directive ensures your medical decisions align with your wishes.³

4. Life Insurance Planning

Life insurance is an essential estate planning tool for physicians, providing liquidity to cover estate taxes, debts, or income replacement for your family. A properly structured life insurance trust can help ensure that policy proceeds remain outside of your taxable estate while being efficiently distributed according to your wishes.⁴

5. Business Succession Planning

If you own a medical practice, a well-designed succession plan can ensure that your business continues to operate smoothly in your absence. This may involve buy-sell agreements, key-person insurance, or identifying a successor to take over your role.⁵

The Long-Term Benefits of Early Estate Planning

Estate planning is not a one-time event—it’s a process that should evolve with your career, financial growth, and family dynamics. The earlier you begin, the more control you have over your financial future. Here’s why starting early is a strategic advantage:

1. Maximizing Tax Efficiency

Many estate planning strategies, such as gifting assets or establishing irrevocable trusts, are most effective when implemented over time. By spreading out wealth transfers and taking advantage of annual gift exclusions, you can significantly reduce estate tax liability while maintaining financial security.

2. Adjusting for Life Changes

Your financial situation and family needs will change over the years. Marriages, births, career advancements, and new investments all impact your estate planning needs. By starting early, you can make gradual adjustments rather than facing an overwhelming restructuring later in life.¹

3. Ensuring Asset Protection Strategies Are in Place

Many asset protection strategies require time to be effective. For instance, certain types of trusts must be in place for a number of years before they fully shield assets from legal claims. Delaying planning could leave your wealth unnecessarily exposed.

4. Creating a Legacy Beyond Wealth

Estate planning is not just about finances—it’s about legacy. Whether you want to support a charitable cause, endow a scholarship, or establish a foundation, early planning gives you the ability to shape your long-term impact.

5. Adapt to Ever Changing Legislation

Estate planning needs to be adaptable. The federal government can change the estate tax exemption at any time; this was even a topic of the last election cycle. Early planning allows you to implement necessary changes throughout your life to minimize estate taxes. At present, unless new policy is enacted, the exemption per individual will reduce by half in 2026 (see Figure 1).

Final Thoughts: Taking Action Today

Estate planning is a powerful tool for physicians looking to protect their wealth, provide for their families, and leave a lasting legacy. The complexity of physician finances—ranging from high income and significant assets to legal risks—makes individualized estate planning an absolute necessity.

By taking proactive steps today, you can maximize tax efficiency, safeguard your assets, and ensure your wishes are carried out without unnecessary delays or legal battles. Working with a financial advisor and estate planning attorney who understands the unique needs of physicians can help you craft a plan that aligns with your goals and evolves as your career progresses.

Mr. Gardner is a financial advisor at Lifetime Financial Growth, LLC, in Columbus, Ohio, one of the largest privately held wealth management firms in the country. John has had a passion for finance since his early years in college when his tennis coach introduced him. He also has a passion for helping physicians, as his wife is a gastroenterologist at Ohio State University. He reports no relevant disclosures relevant to this article. If you have additional questions, please contact John at 740-403-4891 or john_s_gardner@glic.com.

References

1. The Law Offices of Diron Rutty, LLC. https://www.dironruttyllc.com/reasons-to-start-estate-planning-early/. 

2. Physician Side Gigs. https://www.physiciansidegigs.com/estateplanning.

3. Afshar, A & MacBeth, S. https://www.schwabe.com/publication/estate-planning-for-physicians-why-its-important-and-how-to-get-started/. December 2024. 

4. Skeeles, JC. https://ohioline.osu.edu/factsheet/ep-1. July 2012.

5. Rosenfeld, J. Physician estate planning guide. Medical Economics. 2022 Nov. https://www.medicaleconomics.com/view/physician-estate-planning-guide.

As a physician, you’ve spent years building a career that not only provides financial security for your family but also allows you to make a meaningful impact in your community. However, without a comprehensive estate plan in place, much of what you’ve worked so hard to build may not be preserved according to your wishes.

Many physicians delay estate planning, assuming it’s something to consider later in life. However, the most successful estate plans are those that are established early and evolve over time. Proper planning ensures that your assets are protected, your loved ones are provided for, and your legacy is preserved in the most tax-efficient and legally-sound manner possible.¹

This article explores why estate planning is particularly crucial for physicians, the key elements of a strong estate plan, and how beginning early can create long-term financial advantages.

 

Why Estate Planning Matters for Physicians

Physicians are in a unique financial position compared to many other professionals. With high earning potential, specialized assets, and significant liability exposure, their estate planning needs differ from those of the average individual. A well-structured estate plan not only facilitates the smooth transfer of wealth but also protects assets from excessive taxation, legal complications, and potential risks such as malpractice claims.

1. High Net-Worth Considerations

Physicians often accumulate substantial wealth over time. Without a clear estate plan, your estate could face excessive taxation, with a large portion of your assets potentially going to the government rather than your heirs. Estate taxes, probate costs, and legal fees can significantly erode your legacy if not properly planned for.

2. Asset Protection from Liability Risks

Unlike most professionals, physicians are at a higher risk of litigation. A comprehensive estate plan can incorporate asset protection strategies, such as irrevocable trusts, family limited partnerships, or liability insurance, to shield your wealth from lawsuits or creditor claims.

3. Family and Generational Wealth Planning

Many physicians prioritize ensuring their family’s financial stability. Whether you want to provide for your spouse, children, or even charitable causes, estate planning allows you to dictate how your wealth is distributed. Establishing trusts for your children or grandchildren can help manage how and when they receive their inheritance, preventing mismanagement and ensuring financial responsibility.

4. Business and Practice Continuity

If you own a medical practice, succession planning should be part of your estate plan. Without clear directives, the future of your practice may be uncertain in the event of your passing or incapacitation. A well-drafted estate plan provides a roadmap for ownership transition, ensuring continuity for patients, employees, and business partners.

Key Elements of an Effective Estate Plan

Every estate plan should be customized based on your financial situation, goals, and family dynamics. However, certain fundamental components apply to nearly all high-net-worth individuals, including physicians.

1. Revocable Living Trusts

A revocable living trust allows you to manage your assets during your lifetime while providing a clear path for distribution after your passing. Unlike a will, a trust helps your estate avoid probate, ensuring a smoother and more private transition of wealth. You maintain control over your assets while also establishing clear rules for distribution, particularly useful if you have minor children or complex family structures.²

2. Irrevocable Trusts for Asset Protection

For physicians concerned about lawsuits or estate tax exposure, irrevocable trusts can offer robust asset protection. Since assets placed in these trusts are no longer legally owned by you, they are shielded from creditors and legal claims while also reducing your taxable estate.²

3. Powers of Attorney and Healthcare Directives

Estate planning isn’t just about what happens after your passing—it’s also about protecting you and your family if you become incapacitated. A durable power of attorney allows a trusted individual to manage your financial affairs, while a healthcare directive ensures your medical decisions align with your wishes.³

4. Life Insurance Planning

Life insurance is an essential estate planning tool for physicians, providing liquidity to cover estate taxes, debts, or income replacement for your family. A properly structured life insurance trust can help ensure that policy proceeds remain outside of your taxable estate while being efficiently distributed according to your wishes.⁴

5. Business Succession Planning

If you own a medical practice, a well-designed succession plan can ensure that your business continues to operate smoothly in your absence. This may involve buy-sell agreements, key-person insurance, or identifying a successor to take over your role.⁵

The Long-Term Benefits of Early Estate Planning

Estate planning is not a one-time event—it’s a process that should evolve with your career, financial growth, and family dynamics. The earlier you begin, the more control you have over your financial future. Here’s why starting early is a strategic advantage:

1. Maximizing Tax Efficiency

Many estate planning strategies, such as gifting assets or establishing irrevocable trusts, are most effective when implemented over time. By spreading out wealth transfers and taking advantage of annual gift exclusions, you can significantly reduce estate tax liability while maintaining financial security.

2. Adjusting for Life Changes

Your financial situation and family needs will change over the years. Marriages, births, career advancements, and new investments all impact your estate planning needs. By starting early, you can make gradual adjustments rather than facing an overwhelming restructuring later in life.¹

3. Ensuring Asset Protection Strategies Are in Place

Many asset protection strategies require time to be effective. For instance, certain types of trusts must be in place for a number of years before they fully shield assets from legal claims. Delaying planning could leave your wealth unnecessarily exposed.

4. Creating a Legacy Beyond Wealth

Estate planning is not just about finances—it’s about legacy. Whether you want to support a charitable cause, endow a scholarship, or establish a foundation, early planning gives you the ability to shape your long-term impact.

5. Adapt to Ever Changing Legislation

Estate planning needs to be adaptable. The federal government can change the estate tax exemption at any time; this was even a topic of the last election cycle. Early planning allows you to implement necessary changes throughout your life to minimize estate taxes. At present, unless new policy is enacted, the exemption per individual will reduce by half in 2026 (see Figure 1).

Final Thoughts: Taking Action Today

Estate planning is a powerful tool for physicians looking to protect their wealth, provide for their families, and leave a lasting legacy. The complexity of physician finances—ranging from high income and significant assets to legal risks—makes individualized estate planning an absolute necessity.

By taking proactive steps today, you can maximize tax efficiency, safeguard your assets, and ensure your wishes are carried out without unnecessary delays or legal battles. Working with a financial advisor and estate planning attorney who understands the unique needs of physicians can help you craft a plan that aligns with your goals and evolves as your career progresses.

Mr. Gardner is a financial advisor at Lifetime Financial Growth, LLC, in Columbus, Ohio, one of the largest privately held wealth management firms in the country. John has had a passion for finance since his early years in college when his tennis coach introduced him. He also has a passion for helping physicians, as his wife is a gastroenterologist at Ohio State University. He reports no relevant disclosures relevant to this article. If you have additional questions, please contact John at 740-403-4891 or john_s_gardner@glic.com.

References

1. The Law Offices of Diron Rutty, LLC. https://www.dironruttyllc.com/reasons-to-start-estate-planning-early/. 

2. Physician Side Gigs. https://www.physiciansidegigs.com/estateplanning.

3. Afshar, A & MacBeth, S. https://www.schwabe.com/publication/estate-planning-for-physicians-why-its-important-and-how-to-get-started/. December 2024. 

4. Skeeles, JC. https://ohioline.osu.edu/factsheet/ep-1. July 2012.

5. Rosenfeld, J. Physician estate planning guide. Medical Economics. 2022 Nov. https://www.medicaleconomics.com/view/physician-estate-planning-guide.

Dear colleagues,

Lower gastrointestinal bleeding (LGIB) remains a frequent and sometimes perplexing clinical challenge. Despite advancements in endoscopic and radiologic tools, questions persist: What is the role and optimal timing of colonoscopy? How can we best utilize radiologic studies like CTA or tagged RBC scans? How should we manage patients with recurrent or intermittent bleeding that defies localization?

In this issue of Perspectives, Dr. David Wan, Dr. Fredella Lee, and Dr. Zeyad Metwalli offer their expert insights on these difficult questions. Dr. Wan, drawing on over 15 years of experience as a GI hospitalist, shares – along with his coauthor Dr. Lee – a pragmatic approach to LGIB based on clinical patterns, evolving data, and multidisciplinary collaboration. Dr. Metwalli provides the interventional radiologist’s perspective, highlighting how angiographic techniques can complement GI management and introducing novel IR strategies for patients with recurrent or elusive bleeding.

We hope their perspectives will offer valuable guidance for your practice. Join the conversation on X at @AGA_GIHN. 

Gyanprakash A. Ketwaroo, MD, MSc, is associate professor of medicine, Yale University, New Haven, and chief of endoscopy at West Haven VA Medical Center, both in Connecticut. He is an associate editor for GI & Hepatology News.

Management of Lower Gastrointestinal Bleeds: GI Perspective

BY FREDELLA LEE, MD; DAVID WAN, MD

 

Acute lower gastrointestinal bleeding (LGIB) presents unique challenges. Much of this stems from the natural history of diverticular bleeding, the most common etiology of LGIB.

First, while bleeding can be severe, most will spontaneously stop. Second, despite our best efforts with imaging or colonoscopy, finding an intervenable lesion is rare. Third, LGIB has significant rates of rebleeding that are unpredictable.

While serving as a GI hospitalist for 15 years and after managing over 300 cases of LGIB, I often find myself frustrated and colonoscopy feels futile. So how can we rationally approach these patients? We will focus on three clinical questions to develop a framework for LGIB management.

• What is the role and timing for a colonoscopy?
• How do we best utilize radiologic tests?
• How can we prevent recurrent LGIB?

The Role of Colonoscopy

Traditionally, colonoscopy within 24 hours of presentation was recommended. This was based on retrospective cohort data showing higher endoscopic intervention rates and better clinical outcomes. However, this protocol requires patients to drink a significant volume of bowel preparation over a few hours (often requiring an NGT) to achieve clear rectal effluent. Moreover, one needs to mobilize a team (i.e., nurse, technician, anesthesiologist, and gastroenterologist), and find an appropriate location to scope (i.e., ED, ICU, or OR), Understandably, this is challenging, especially overnight. When the therapeutic yield is relatively low, this approach quickly loses enthusiasm.

Importantly, meta-analyses of the randomized controlled trials, have shown that urgent colonoscopies (<24 hours upon presentation), compared to elective colonoscopies (>24 hours upon presentation), do not improve clinical outcomes such as re-bleeding rates, transfusion requirements, mortality, or length of stay. In these studies, the endoscopic intervention rates were 17-34%, however, observational data shows rates of only 8%. In our practice, we will use a clear cap attachment device and water jet irrigation to increase the odds of detecting an active source of bleeding. Colonoscopy has a diagnostic yield of 95% – despite its low therapeutic yield; and while diverticular bleeds constitute up to 64% of cases, one does not want to miss colorectal cancer or other diagnoses. Regardless, there is generally no urgency to perform a colonoscopy. To quote a colleague, Dr. Elizabeth Ross, “there is no such thing as door-to-butt time.”

The Role of Radiology

Given the limits of colonoscopy, can radiographic tests such as computed tomography angiography (CTA) or tagged red blood cell (RBC) scan be helpful? Multiple studies have suggested using CTA as the initial diagnostic test. The advantages of CTAs are:

• Fast, readily available, and does not require a bowel preparation
• If negative, CTAs portend a good prognosis and make it highly unlikely to detect active extravasation on visceral angiography
• If positive, can localize the source of bleed and increase the success of intervention

Whether a positive CTA should be followed with a colonoscopy or visceral angiography remains unclear. Studies show that positive CTAs increase the detection rate of stigmata of recent hemorrhage on colonoscopy. Positive CTAs can also identify a target for embolization by interventional radiology (IR). Though an important caveat is that the success rate of embolization is highest when performed within 90 minutes of a positive CTA. This highlights that if you have IR availability, it is critical to have clear communication, a well-defined protocol, and collaboration among disciplines (i.e., ED, medical team, GI, and IR).

At our institution, we have implemented a CTA-guided protocol for severe LGIB. Those with positive CTAs are referred immediately to IR for embolization. If the embolization is unsuccessful or CTA is negative, the patient will be planned for a non-urgent inpatient colonoscopy. However, our unpublished data and other studies have shown that the overall CTA positivity rates are only between 16-22%. Moreover, one randomized controlled trial comparing CTA versus colonoscopy as an initial test did not show any meaningful difference in clinical outcomes. Thus, the benefit of CTA and the best approach to positive CTAs remains in question.

Lastly, people often ask about the utility of RBC nuclear scans. While they can detect bleeds at a slower rate (as low as 0.1 mL/min) compared to CTA (at least 0.4 mL/min), there are many limitations. RBC scans take time, are not available 24-7, and cannot precisely localize the site of bleeding. Therefore, we rarely recommend them for LGIB.

 

Approach to Recurrent Diverticular Bleeding

Unfortunately, diverticular bleeding recurs in the hospital 14% of the time and up to 25% at 5 years. When this occurs, is it worthwhile to repeat another colonoscopy or CTA?

Given the lack of clear data, we have adopted a shared decision-making framework with patients. Oftentimes, these patients are older and have significant co-morbidities, and undergoing bowel preparation, anesthesia, and colonoscopy is not trivial. If the patient is stable and prior work-up has excluded pertinent alternative diagnoses other than diverticular bleeding, then we tell patients the chance of finding an intervenable lesion is low and opt for conservative management. Meanwhile, if the patient has persistent, hemodynamically significant bleeding, we recommend a CTA based on the rationale discussed previously.

The most important clinical decision may not be about scoping or obtaining a CTA – it is medication management. If they are taking NSAIDs, they should be discontinued. If antiplatelet or anticoagulation agents were held, they should be restarted promptly in individuals with significant thrombotic risk given studies showing that while rebleeding rates may increase, overall mortality decreases.

In summary, managing LGIB and altering its natural history with either endoscopic or radiographic means is challenging. More studies are needed to guide the optimal approach. Reassuringly, most bleeding self-resolves and patients have good clinical outcomes.

Dr. Lee is a resident physician at New York Presbyterian Weill Cornell Medical Center, New York, NY. Dr. Wan is associate professor of clinical medicine at Weill Cornell Medicine, New York, N.Y. They declare no conflicts of interest.

Lower Gastrointestinal Bleeding: An Interventional Radiologist’s Perspective

BY ZEYAD METWALLI, MD, FSIR

 

When colonoscopy fails to localize and/or stop lower gastrointestinal bleeding (LGIB), catheter angiography has been commonly employed as a tool for both diagnosis and treatment of bleeding with embolization. Nuclear medicine or CT imaging studies can serve as useful adjuncts for confirming active bleeding and localizing the site of bleeding prior to angiography, particularly if this information is not provided by colonoscopy. Provocative mesenteric angiography has also become increasingly popular as a troubleshooting technique in patients with initially negative angiography.

Localization of Lower Gastrointestinal Bleeding

Radionuclide technetium-99m-lableled red blood cell scintigraphy (RBCS), also known as tagged RBC scintigraphy, has been in use since the early 1980s for investigation of acute gastrointestinal bleeding. RBCS has a high sensitivity for detection of active bleeding with a theoretical ability to detect bleeding at rates as low as 0.04-0.2 mL/minute.

Imaging protocols vary but should include dynamic images, which may aid in localization of bleeding. The relatively long half-life of the tracer used for imaging allows for delayed imaging 12 to 24 hours after injection. This can be useful to confirm active bleeding, particularly when bleeding is intermittent and is not visible on initial images. 

With the advent of computed tomography angiography (CTA), which continues to increase in speed, imaging quality and availability, the use of RBCS for evaluation of LGIB has declined. CTA is quicker to perform than RBCS and allows for detection of bleeding as well as accurate anatomic localization, which can guide interventions.

CTA provides a more comprehensive anatomic evaluation, which can aid in the diagnosis of a wide variety of intra-abdominal issues. Conversely, CTA may be less sensitive than RBCS for detection of slower acute bleeding, detecting bleeding at rates of 0.1-1 mL/min. In addition, intermittent bleeding which has temporarily stopped at the time of CTA may evade detection.

Lastly, CTA may not be appropriate in patients with impaired renal function due to risk of contrast-induced nephropathy, particularly in patients with acute kidney injury, which commonly afflicts hospitalized patients with LGIB. Prophylaxis with normal saline hydration should be employed aggressively in patients with impaired renal function, particularly when eGFR is less than 30 mL/minute. Iodinated contrast should be used judiciously in these patients.

In clinical practice, CTA and RBCS have a similar ability to confirm the presence or absence of clinically significant active gastrointestinal bleeding. Given the greater ability to rapidly localize the bleeding site with CTA, this is generally preferred over RBCS unless there is a contraindication to performing CTA, such as severe contrast allergy or high risk for development of contrast-induced nephropathy.

 

Role of Catheter Angiography and Embolization

Mesenteric angiography is a well-established technique for both detection and treatment of LGIB. Hemodynamic instability and need for packed RBC transfusion increases the likelihood of positive angiography. Limitations include reduced sensitivity for detection of bleeding slower than 0.5-1 mL/minute as well as the intermittent nature of LGIB, which will often resolve spontaneously. Angiography is variably successful in the literature with a diagnostic yield between 40-80%, which encompasses the rate of success in my own practice.

Once bleeding is identified, microcatheter placement within the feeding vessel as close as possible to the site of bleeding is important to ensure treatment efficacy and to limit risk of complications such as non-target embolization and bowel ischemia. Once the feeding vessel is selected with a microcatheter, embolization can be accomplished with a wide variety of tools including metallic coils, liquid embolic agents, and particles. In the treatment of LGIB, liquid embolic agents (e.g., n-butyl cyanoacrylate or NBCA, ethylene vinyl alcohol copolymer, etc.) and particles should be used judiciously as distal penetration increases the risk of bowel ischemia and procedure-related morbidity. For this reason, metallic coils are often preferred in the treatment of LGIB.

Although the source of bleeding is variable and may include diverticulosis, recent polypectomy, ulcer, tumor or angiodysplasia, the techniques employed are similar. Accurate and distal microcatheter selection is a key driver for successful embolization and minimizing the risk of bowel ischemia. Small intestinal bleeds can be challenging to treat due to the redundant supply of the arterial arcades supplying small bowel and may require occlusion of several branches to achieve hemostasis. This approach must be balanced with the risk of developing ischemia after embolization. Angiodysplasia, a less frequently encountered culprit of LGIB, may also be managed with selective embolization with many reports of successful treatment with liquid embolic agents such as NBCA mixed with ethiodized oil.

 

Provocative Mesenteric Angiography for Occult Bleeding

When initial angiography in a patient with suspected active LGIB is negative, provocative angiography can be considered to uncover an intermittent bleed. This may be particularly helpful in a patient where active bleeding is confirmed on a prior diagnostic test.

The approach to provocative mesenteric angiography varies by center, and a variety of agents have been used to provoke bleeding including heparin, vasodilators (i.e., nitroglycerin, verapamil, etc.) and thrombolytics (i.e., tPA), often in combination. Thrombolytics can be administered directly into the territory of interest (i.e., superior mesenteric or inferior mesenteric artery) while heparin may be administered systemically or directly into the catheterized artery. Reported success rates for provoking angiographically visible bleeding vary, but most larger series report a 40-50% success rate. The newly detected bleeding can then be treated with either embolization or surgery. A surgeon should be involved and available when provocative angiography is planned should bleeding fail to be controlled by embolization.

In summary, when colonoscopy fails to identify or control lower gastrointestinal bleeding (LGIB), imaging techniques such as RBCS and CTA play a crucial role in localizing active bleeding. While RBCS is highly sensitive, especially for intermittent or slow bleeding, CTA offers faster, more detailed anatomical information and is typically preferred unless contraindicated by renal issues or contrast allergies. Catheter-based mesenteric angiography is a well-established method for both diagnosing and treating LGIB, often using metallic coils to minimize complications like bowel ischemia. In cases where initial angiography is negative, provocative angiography – using agents like heparin or thrombolytics – may help unmask intermittent bleeding, allowing for targeted embolization or surgical intervention.

Dr. Metwalli is associate professor in the Department of Interventional Radiology, Division of Diagnostic Imaging, at The University of Texas MD Anderson Cancer Center, Houston, Texas. He declares no conflicts of interest.

Dear colleagues,

Lower gastrointestinal bleeding (LGIB) remains a frequent and sometimes perplexing clinical challenge. Despite advancements in endoscopic and radiologic tools, questions persist: What is the role and optimal timing of colonoscopy? How can we best utilize radiologic studies like CTA or tagged RBC scans? How should we manage patients with recurrent or intermittent bleeding that defies localization?

In this issue of Perspectives, Dr. David Wan, Dr. Fredella Lee, and Dr. Zeyad Metwalli offer their expert insights on these difficult questions. Dr. Wan, drawing on over 15 years of experience as a GI hospitalist, shares – along with his coauthor Dr. Lee – a pragmatic approach to LGIB based on clinical patterns, evolving data, and multidisciplinary collaboration. Dr. Metwalli provides the interventional radiologist’s perspective, highlighting how angiographic techniques can complement GI management and introducing novel IR strategies for patients with recurrent or elusive bleeding.

We hope their perspectives will offer valuable guidance for your practice. Join the conversation on X at @AGA_GIHN. 

Gyanprakash A. Ketwaroo, MD, MSc, is associate professor of medicine, Yale University, New Haven, and chief of endoscopy at West Haven VA Medical Center, both in Connecticut. He is an associate editor for GI & Hepatology News.

Management of Lower Gastrointestinal Bleeds: GI Perspective

BY FREDELLA LEE, MD; DAVID WAN, MD

 

Acute lower gastrointestinal bleeding (LGIB) presents unique challenges. Much of this stems from the natural history of diverticular bleeding, the most common etiology of LGIB.

First, while bleeding can be severe, most will spontaneously stop. Second, despite our best efforts with imaging or colonoscopy, finding an intervenable lesion is rare. Third, LGIB has significant rates of rebleeding that are unpredictable.

While serving as a GI hospitalist for 15 years and after managing over 300 cases of LGIB, I often find myself frustrated and colonoscopy feels futile. So how can we rationally approach these patients? We will focus on three clinical questions to develop a framework for LGIB management.

• What is the role and timing for a colonoscopy?
• How do we best utilize radiologic tests?
• How can we prevent recurrent LGIB?

The Role of Colonoscopy

Traditionally, colonoscopy within 24 hours of presentation was recommended. This was based on retrospective cohort data showing higher endoscopic intervention rates and better clinical outcomes. However, this protocol requires patients to drink a significant volume of bowel preparation over a few hours (often requiring an NGT) to achieve clear rectal effluent. Moreover, one needs to mobilize a team (i.e., nurse, technician, anesthesiologist, and gastroenterologist), and find an appropriate location to scope (i.e., ED, ICU, or OR), Understandably, this is challenging, especially overnight. When the therapeutic yield is relatively low, this approach quickly loses enthusiasm.

Importantly, meta-analyses of the randomized controlled trials, have shown that urgent colonoscopies (<24 hours upon presentation), compared to elective colonoscopies (>24 hours upon presentation), do not improve clinical outcomes such as re-bleeding rates, transfusion requirements, mortality, or length of stay. In these studies, the endoscopic intervention rates were 17-34%, however, observational data shows rates of only 8%. In our practice, we will use a clear cap attachment device and water jet irrigation to increase the odds of detecting an active source of bleeding. Colonoscopy has a diagnostic yield of 95% – despite its low therapeutic yield; and while diverticular bleeds constitute up to 64% of cases, one does not want to miss colorectal cancer or other diagnoses. Regardless, there is generally no urgency to perform a colonoscopy. To quote a colleague, Dr. Elizabeth Ross, “there is no such thing as door-to-butt time.”

The Role of Radiology

Given the limits of colonoscopy, can radiographic tests such as computed tomography angiography (CTA) or tagged red blood cell (RBC) scan be helpful? Multiple studies have suggested using CTA as the initial diagnostic test. The advantages of CTAs are:

• Fast, readily available, and does not require a bowel preparation
• If negative, CTAs portend a good prognosis and make it highly unlikely to detect active extravasation on visceral angiography
• If positive, can localize the source of bleed and increase the success of intervention

Whether a positive CTA should be followed with a colonoscopy or visceral angiography remains unclear. Studies show that positive CTAs increase the detection rate of stigmata of recent hemorrhage on colonoscopy. Positive CTAs can also identify a target for embolization by interventional radiology (IR). Though an important caveat is that the success rate of embolization is highest when performed within 90 minutes of a positive CTA. This highlights that if you have IR availability, it is critical to have clear communication, a well-defined protocol, and collaboration among disciplines (i.e., ED, medical team, GI, and IR).

At our institution, we have implemented a CTA-guided protocol for severe LGIB. Those with positive CTAs are referred immediately to IR for embolization. If the embolization is unsuccessful or CTA is negative, the patient will be planned for a non-urgent inpatient colonoscopy. However, our unpublished data and other studies have shown that the overall CTA positivity rates are only between 16-22%. Moreover, one randomized controlled trial comparing CTA versus colonoscopy as an initial test did not show any meaningful difference in clinical outcomes. Thus, the benefit of CTA and the best approach to positive CTAs remains in question.

Lastly, people often ask about the utility of RBC nuclear scans. While they can detect bleeds at a slower rate (as low as 0.1 mL/min) compared to CTA (at least 0.4 mL/min), there are many limitations. RBC scans take time, are not available 24-7, and cannot precisely localize the site of bleeding. Therefore, we rarely recommend them for LGIB.

 

Approach to Recurrent Diverticular Bleeding

Unfortunately, diverticular bleeding recurs in the hospital 14% of the time and up to 25% at 5 years. When this occurs, is it worthwhile to repeat another colonoscopy or CTA?

Given the lack of clear data, we have adopted a shared decision-making framework with patients. Oftentimes, these patients are older and have significant co-morbidities, and undergoing bowel preparation, anesthesia, and colonoscopy is not trivial. If the patient is stable and prior work-up has excluded pertinent alternative diagnoses other than diverticular bleeding, then we tell patients the chance of finding an intervenable lesion is low and opt for conservative management. Meanwhile, if the patient has persistent, hemodynamically significant bleeding, we recommend a CTA based on the rationale discussed previously.

The most important clinical decision may not be about scoping or obtaining a CTA – it is medication management. If they are taking NSAIDs, they should be discontinued. If antiplatelet or anticoagulation agents were held, they should be restarted promptly in individuals with significant thrombotic risk given studies showing that while rebleeding rates may increase, overall mortality decreases.

In summary, managing LGIB and altering its natural history with either endoscopic or radiographic means is challenging. More studies are needed to guide the optimal approach. Reassuringly, most bleeding self-resolves and patients have good clinical outcomes.

Dr. Lee is a resident physician at New York Presbyterian Weill Cornell Medical Center, New York, NY. Dr. Wan is associate professor of clinical medicine at Weill Cornell Medicine, New York, N.Y. They declare no conflicts of interest.

Lower Gastrointestinal Bleeding: An Interventional Radiologist’s Perspective

BY ZEYAD METWALLI, MD, FSIR

 

When colonoscopy fails to localize and/or stop lower gastrointestinal bleeding (LGIB), catheter angiography has been commonly employed as a tool for both diagnosis and treatment of bleeding with embolization. Nuclear medicine or CT imaging studies can serve as useful adjuncts for confirming active bleeding and localizing the site of bleeding prior to angiography, particularly if this information is not provided by colonoscopy. Provocative mesenteric angiography has also become increasingly popular as a troubleshooting technique in patients with initially negative angiography.

Localization of Lower Gastrointestinal Bleeding

Radionuclide technetium-99m-lableled red blood cell scintigraphy (RBCS), also known as tagged RBC scintigraphy, has been in use since the early 1980s for investigation of acute gastrointestinal bleeding. RBCS has a high sensitivity for detection of active bleeding with a theoretical ability to detect bleeding at rates as low as 0.04-0.2 mL/minute.

Imaging protocols vary but should include dynamic images, which may aid in localization of bleeding. The relatively long half-life of the tracer used for imaging allows for delayed imaging 12 to 24 hours after injection. This can be useful to confirm active bleeding, particularly when bleeding is intermittent and is not visible on initial images. 

With the advent of computed tomography angiography (CTA), which continues to increase in speed, imaging quality and availability, the use of RBCS for evaluation of LGIB has declined. CTA is quicker to perform than RBCS and allows for detection of bleeding as well as accurate anatomic localization, which can guide interventions.

CTA provides a more comprehensive anatomic evaluation, which can aid in the diagnosis of a wide variety of intra-abdominal issues. Conversely, CTA may be less sensitive than RBCS for detection of slower acute bleeding, detecting bleeding at rates of 0.1-1 mL/min. In addition, intermittent bleeding which has temporarily stopped at the time of CTA may evade detection.

Lastly, CTA may not be appropriate in patients with impaired renal function due to risk of contrast-induced nephropathy, particularly in patients with acute kidney injury, which commonly afflicts hospitalized patients with LGIB. Prophylaxis with normal saline hydration should be employed aggressively in patients with impaired renal function, particularly when eGFR is less than 30 mL/minute. Iodinated contrast should be used judiciously in these patients.

In clinical practice, CTA and RBCS have a similar ability to confirm the presence or absence of clinically significant active gastrointestinal bleeding. Given the greater ability to rapidly localize the bleeding site with CTA, this is generally preferred over RBCS unless there is a contraindication to performing CTA, such as severe contrast allergy or high risk for development of contrast-induced nephropathy.

 

Role of Catheter Angiography and Embolization

Mesenteric angiography is a well-established technique for both detection and treatment of LGIB. Hemodynamic instability and need for packed RBC transfusion increases the likelihood of positive angiography. Limitations include reduced sensitivity for detection of bleeding slower than 0.5-1 mL/minute as well as the intermittent nature of LGIB, which will often resolve spontaneously. Angiography is variably successful in the literature with a diagnostic yield between 40-80%, which encompasses the rate of success in my own practice.

Once bleeding is identified, microcatheter placement within the feeding vessel as close as possible to the site of bleeding is important to ensure treatment efficacy and to limit risk of complications such as non-target embolization and bowel ischemia. Once the feeding vessel is selected with a microcatheter, embolization can be accomplished with a wide variety of tools including metallic coils, liquid embolic agents, and particles. In the treatment of LGIB, liquid embolic agents (e.g., n-butyl cyanoacrylate or NBCA, ethylene vinyl alcohol copolymer, etc.) and particles should be used judiciously as distal penetration increases the risk of bowel ischemia and procedure-related morbidity. For this reason, metallic coils are often preferred in the treatment of LGIB.

Although the source of bleeding is variable and may include diverticulosis, recent polypectomy, ulcer, tumor or angiodysplasia, the techniques employed are similar. Accurate and distal microcatheter selection is a key driver for successful embolization and minimizing the risk of bowel ischemia. Small intestinal bleeds can be challenging to treat due to the redundant supply of the arterial arcades supplying small bowel and may require occlusion of several branches to achieve hemostasis. This approach must be balanced with the risk of developing ischemia after embolization. Angiodysplasia, a less frequently encountered culprit of LGIB, may also be managed with selective embolization with many reports of successful treatment with liquid embolic agents such as NBCA mixed with ethiodized oil.

 

Provocative Mesenteric Angiography for Occult Bleeding

When initial angiography in a patient with suspected active LGIB is negative, provocative angiography can be considered to uncover an intermittent bleed. This may be particularly helpful in a patient where active bleeding is confirmed on a prior diagnostic test.

The approach to provocative mesenteric angiography varies by center, and a variety of agents have been used to provoke bleeding including heparin, vasodilators (i.e., nitroglycerin, verapamil, etc.) and thrombolytics (i.e., tPA), often in combination. Thrombolytics can be administered directly into the territory of interest (i.e., superior mesenteric or inferior mesenteric artery) while heparin may be administered systemically or directly into the catheterized artery. Reported success rates for provoking angiographically visible bleeding vary, but most larger series report a 40-50% success rate. The newly detected bleeding can then be treated with either embolization or surgery. A surgeon should be involved and available when provocative angiography is planned should bleeding fail to be controlled by embolization.

In summary, when colonoscopy fails to identify or control lower gastrointestinal bleeding (LGIB), imaging techniques such as RBCS and CTA play a crucial role in localizing active bleeding. While RBCS is highly sensitive, especially for intermittent or slow bleeding, CTA offers faster, more detailed anatomical information and is typically preferred unless contraindicated by renal issues or contrast allergies. Catheter-based mesenteric angiography is a well-established method for both diagnosing and treating LGIB, often using metallic coils to minimize complications like bowel ischemia. In cases where initial angiography is negative, provocative angiography – using agents like heparin or thrombolytics – may help unmask intermittent bleeding, allowing for targeted embolization or surgical intervention.

Dr. Metwalli is associate professor in the Department of Interventional Radiology, Division of Diagnostic Imaging, at The University of Texas MD Anderson Cancer Center, Houston, Texas. He declares no conflicts of interest.

Dear colleagues,

Lower gastrointestinal bleeding (LGIB) remains a frequent and sometimes perplexing clinical challenge. Despite advancements in endoscopic and radiologic tools, questions persist: What is the role and optimal timing of colonoscopy? How can we best utilize radiologic studies like CTA or tagged RBC scans? How should we manage patients with recurrent or intermittent bleeding that defies localization?

In this issue of Perspectives, Dr. David Wan, Dr. Fredella Lee, and Dr. Zeyad Metwalli offer their expert insights on these difficult questions. Dr. Wan, drawing on over 15 years of experience as a GI hospitalist, shares – along with his coauthor Dr. Lee – a pragmatic approach to LGIB based on clinical patterns, evolving data, and multidisciplinary collaboration. Dr. Metwalli provides the interventional radiologist’s perspective, highlighting how angiographic techniques can complement GI management and introducing novel IR strategies for patients with recurrent or elusive bleeding.

We hope their perspectives will offer valuable guidance for your practice. Join the conversation on X at @AGA_GIHN. 

Gyanprakash A. Ketwaroo, MD, MSc, is associate professor of medicine, Yale University, New Haven, and chief of endoscopy at West Haven VA Medical Center, both in Connecticut. He is an associate editor for GI & Hepatology News.