Geriatric Gastroenterology

C.S. Pitchumoni
Editors

T.S. Dharmarajan

Geriatric Gastroenterology

Editors C.S. Pitchumoni, MD, MPH, FRCP(C), MACP MACG, AGAF Clinical Professor of Medicine Robert Wood Johnson School of Medicine Drexel University School of Medicine Adjunct Professor of Medicine New York Medical College, Valhalla, NY Chief, Gastroenterology, Hepatology and Nutrition Saint Peters University Hospital New Brunswick, NJ, USA

T.S. Dharmarajan, MD, FACP, AGSF Professor of Medicine Associate Dean New York Medical College, Valhalla, NY Vice Chairman, Department of Medicine Clinical Director, Division of Geriatrics Program Director, Geriatric Medicine Fellowship Program Montefiore Medical Center (North Division) Bronx, New York, USA

Please note that additional material for this book can be downloaded from http://extras.springer.com ISBN 978-1-4419-1622-8 ISBN 978-1-4419-1623-5 (eBook) DOI 10.1007/978-1-4419-1623-5 Springer New York Heidelberg Dordrecht London
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Dedicated to my parents, My wife, Prema And children Sheila, Shoba and Suresh For love, encouragement and understanding! CSP Dedicated to my mother, My wife, Lekshmi, And, Kumar and Kavita, With love and gratitude, TSD

Foreword

The denition of old age is not a clear one; most societies use arbitrary language to dene the older adult. One hundred years ago, old age was dened as any age after fty. Later, criteria such as pension schemes evolved to dene the older adult, and ages 60 to 65 are numbers still accepted today. The term geriatrics means related to the aged and geriatric medicine deals with medical problems of old age. Aging is associated with a gradual decline in physiologic processes, along with susceptibility to disease. The needs of the old differ from those of the young. Geriatric patients often present atypically. Both evaluation and care differ. Decisionmaking is inuenced not only by the disease process itself, but also by life expectancy, quality of life issues and patient choices. This book deals with both the physiologic and pathologic changes in the gastrointestinal system as the aging process advances, and with the evaluation and care appropriate to the older age group. The gastroenterology and geriatric medicine disciplines are fortunate to have two experienced editors in Dr. Pitchumoni and Dr. Dharmarajan: they have conceived this book and have brought it to fruition. They are distinguished educators and clinicians who have achieved national and international respect in the elds of gastroenterology, internal medicine and geriatrics. As authors and editors, they have been collaborating for over three decades. Having co-authored a series of articles in geriatric gastroenterology in peer-reviewed journals, they have now taken a step further in the design and execution of this work. The diverse backgrounds of the two editors bring strength and breadth to this ambitious text. Both editors have spent the majority of their professional careers in academic gastroenterology and geriatric medicine respectively. They have published extensively and have served on the editorial boards of prestigious journals. Dr. Pitchumoni, a recognized master teacher, is a Master of both the American College of Physicians and the American College of Gastroenterology. He has advanced degrees and board certication in the elds of internal medicine, gastroenterology, clinical nutrition and public health. Although he considers this author to be his mentor, I have certainly reaped equal benet from our personal and professional relationship over the years. Dr. Dharmarajan, a dedicated geriatrician, developed one of the largest known acute care hospital geriatric programs and associated geriatric medicine fellowships. He also serves as Associate Dean of his afliated medical school. In 1998, he published Launching a Geriatric Unit in Health Progress. The two continued their academic alliance in 2002 with the publication Geriatric Medicine Programs in India: Has the Time Arrived? in the Journal of Association of Physicians India. The present book joins several other textbooks previously edited by this ne team of scholars. This is not just another gastroenterology textbook. The design is unique in providing contemporary information in the eld of gastroenterology pertinent to the older adult. Although not the rst book in geriatric gastroenterology, this rst edition is conceptually bold and novel. The text is a state of the art, comprehensive and practical approach to the clinical practice of internal medicine, geriatrics and gastroenterology. The references are updated
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and current clinical practice guidelines are appropriately presented. The book impresses me as one meant for the practicing physician as well as the resident in training and the fellow in geriatric medicine or gastroenterology. Key points at the end of every chapter summarize the highlights. Every chapter is amply supplemented with easy- to-understand tables and gures. Two chapters are devoted to radiologic images of gastrointestinal disorders in the aged. A chapter dealing with gastrointestinal pathology is rich in photographs of virtually every common gastrointestinal disorder in the elderly. The book as a whole is liberally illustrated with high quality images and clear captions. The editors have done an excellent job in their plan and execution of the contents. Seventy-two chapters are presented in fourteen sections. Introductory chapters present the perspectives of the editors as geriatrician and gastroenterologist. These are followed by a chapter on future trends in health care, and enable clinicians become knowledgeable on management of gastrointestinal disorders in the aged population, a view supported by the American College of Gastroenterology. Chapters follow on the basic sciences and principles of gastroenterology in the context of the older adult and the aging process. Subsequent chapters deal with the important topics of pharmacology and drug interactions. The next few focus on geriatric nutrition, with topics ranging from healthy diet to enteral feeding to ethical issues in end-of-life care. The chapters which follow deal with luminal disorders, malignancies of the gastrointestinal tract, the liver, gallbladder and pancreas, palliative care, systemic disorders, and psychiatric disease. Each chapter focuses on evaluation, differential diagnosis and management of gastrointestinal problems relevant to the older adult. Over eighty authors have contributed to the writing of this book. Many are of national and international repute, and ably supported by junior faculty members. In addition to their role as editors, Dr. Pitchumoni and Dr. Dharmarajan have also contributed a signicant share of book chapters. In summary, this rst edition of Geriatric Gastroenterology is a major attempt to be all-inclusive in the eld of gastroenterology pertinent to the geriatric patient. The information therein is contemporary and basic to the practice of medicine. It is a privilege and honor to write this Foreword. The Editors are world-renowned educators and scholars who have designed and delivered a masterful textbook for clinicians of internal medicine, geriatrics and gastroenterology. They are to be congratulated for this effort. Clinical Professor of Medicine Yale University School of Medicine Martin H. Floch, M.D.

Preface

Over the past several decades, trends in global aging have focused attention on the manner in which we care for older adults. How can we be best prepared to meet the demands of medical illness in our aging population? Many of the medical societies have increasingly promoted the blending of medical sub-specialty training with expertise in the care of the older adult. In this regard, the American Gastroenterologic Association Future Trends Committee Report recently highlighted several areas for improvement in health care delivery, including the need to identify best evidence-based care for the older adult; to develop guidelines for care of specic gastrointestinal issues in geriatrics; to modify current practices in order to meet the complex needs of older individuals; and to adapt the healthcare workforce to meet the demands of specialized treatments in gastroenterology for older people. Until there are sufcient trained personnel in both geriatrics and gastroenterology, providers must handle the daunting task with knowledge gained in other ways. As editors specialized in gastroenterologiy and geriatric medicine, we see the need for a textbook to address the physiology, pathology, evaluation and management of digestive disorders in the elderly. Too often, clinical complaints are attributed to old age by patient and provider alike. Physicians must be better trained to discern physiological from pathological processes and normal aging from disease. Disorders such as constipation and diverticular disease are common in the old, but are they pathological, or the result of aging? As age is associated withimmune dysfunction, the role of the gut in the elderly has become a subject of increasing importance. How should the age-related decline in homestatic mechanisms, known as homeostenosis, alter medical care in the elderly? Added to the complex situation is the impact of polypharmacy and adverse drug events which often mimic gastrointestinal disorders, with increasing health care costs. How can we learn to be more focused and sensitive to these issues? This book attempts to clarity these challenging and controversial issues in the diagnosis and care of the geriatric individual. A standard format has been adopted for this text, whereby most chapters conclude with key summary points. Numerous tables and gures are included to emphasize content. There are abundant pictures focusing on endoscopy, radiography and pathology. Several relevant gastrointestinal topics unique to the older person are included. We anticipate the book will be a valuable resource for residents, fellows, and practicing physicians alike. A section providing Questions with multiple choice Answers and brief discussions relating to the chapters is hosted in an electronic platform (Springer Extras); this may be an additional benet particularly to residents and fellows in training. This work is by no means all-inclusive, but does offer solid grounding in geriatric gastroenterology. It is also not the rst text on the subject: the rst comprehensive book was written in 1984 by Lawrence J. Brandt MD, Emeritus Chairman of Gastroenterology at Albert Einstein College of Medicine, entitled Gastrointestinal Disorders of the Elderly. Tremendous credit is due to Peter R. Holt MD of Saint Lukes Hospital of New York-Presbyterian Medical Center
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for pioneering the concept of Aging and the Gastrointestinal Tract. These two provided the initial motivation for our efforts. We salute as well many pioneers in the eld of Geriatrics: William R. Hazzard, Christine K. Cassel, Joseph G. Ouslander, Mary E. Tinetti, Laurence Z. Rubenstein, John E. Morley, and others; and the eld of Gastroenterology: Howard M. Spiro, Henry L. Bockus, Sir Francis Avery Jones, Dame Sheila Sherlock, Marvin H. Sleisenger, John S. Fordtran, Edward J. Berk, and others. All of these scholar-mentors in medicine paved the path for us to follow. Special thanks are due to Martin H. Floch MD of Yale University, who has graciously provided the Foreword for the book. We are grateful to the many contributors who responded to our call and gave generously of their time to provide chapters for the book. Springer has been supportive from the start of this venture and throughout the editing process. Both of us wrote a series of articles over the past fteen years on the theme of geriatric gastroenterology, and Springer has been instrumental in bringing to fruition our dream of a textbook of geriatric gastroenterology. Support and encouragement from our family was ever present, and for this we are eternally grateful. Our families were a source of strength and inspiration; their patience, understanding and sacrices commendable. As teachers and mentors, we acknowledge our students, residents, fellows and professional colleagues for providing the opportunity to enrich our knowledge and clinical skills. And above all, we pay tribute to our older adult patients in community, hospital and nursing home settings, from whom we have learned so much. It is our hope that this textbook serves as a resource towards fulllment of a goal so aptly stated by Abraham Lincoln: And in the end, its not the years in your life that count. Its the life in your years. C.S. Pitchumoni MD T.S. Dharmarajan MD

Contents

Part I 1 2 3

Perspectives and Trends 3 7 11

Geriatric Gastroenterology: The Geriatricians Perspective ............................... T.S. Dharmarajan Geriatric Gastroenterology: The Gastroenterologists Perspective .................... C.S. Pitchumoni Geriatric Gastroenterology: Future Trends .......................................................... Karen E. Hall Basic Sciences, Principles and Epidemiology

Part II 4 5 6 7

The Physiology of Aging .......................................................................................... T.S. Dharmarajan The Gastrointestinal System and Aging ................................................................ T.S. Dharmarajan, Amit Sohagia, and C.S. Pitchumoni Epidemiology of Gastrointestinal Disease ............................................................. Julia B. Greer, Haq Nawaz, and Dhiraj Yadav Comprehensive Geriatric Assessment .................................................................... T.S. Dharmarajan Pharmacology

17 33 49 55

Part III 8 9 10 11

Drug Effects on the Gastrointestinal Tract............................................................ Vishal Jain, T.S. Dharmarajan, and C.S. Pitchumoni Pharmacokinetics of Aging ..................................................................................... Ryan J. Haumschild DrugNutrient Interactions .................................................................................... Srinivas Guptha Gunturu and T.S. Dharmarajan Probiotics .................................................................................................................. Martin H. Floch Nutrition

73 83 89 99

Part IV 12 13

Geriatric Nutritional Assessment ........................................................................... 107 Kumar Dharmarajan and Kenneth L. Minaker Tube Feeding: Techniques and Procedure ............................................................. 119 Amit Sohagia and Hilary I. Hertan

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14 15

Enteral and Parenteral Nutrition ........................................................................... 127 Manie Juneja and Stephen J.D. OKeefe Ethical Aspects, Expectations, and Outcomes Associated with PEG in Dementia ............................................................................................. 137 T.S. Dharmarajan, Krishna P. Aparanji, and C.S. Pitchumoni Water, Potassium, Sodium, and Chloride in Nutrition ......................................... 145 Kumar Dharmarajan and Kenneth L. Minaker Intravenous Fluid Administration .......................................................................... 153 Eugene C. Corbett, Jr. B12 and Folic Acid ................................................................................................... 161 T.S. Dharmarajan and Srinivas Guptha Gunturu Iron, Copper, and Zinc ............................................................................................ 177 T.S. Dharmarajan, Srinivas Guptha Gunturu, and C.S. Pitchumoni Vitamin D and Calcium ........................................................................................... 185 T.S. Dharmarajan and Amit Sohagia Dietary Fiber in Health and Disease ...................................................................... 197 C.S. Pitchumoni and Fisseha Y. Ghidey Healthy Diet for the Older Adult ............................................................................ 205 Sirakarn Tejavanija and Sunil S. Jhangiani Imaging

16 17 18 19 20 21 22

Part V 23 24 25 26

Endoscopy in Older Adults: Risks, Benets, Considerations .............................. 215 Noelle OShea and Frank J. Lukens Wireless Capsule Endoscopy................................................................................... 221 C.S. Pitchumoni and Neelam G. Gidwaney GastroIntestinal Radiology ..................................................................................... 227 Judith K. Amorosa and C.S. Pitchumoni Advanced Imaging of Geriatric Gastrointestinal Pathology................................ 249 Fernanda Samara Mazzariol Pathology

Part VI 27 28

Laboratory Tests in Older Adults: Indications, Interpretation, Issues............... 261 T.S. Dharmarajan and C.S. Pitchumoni Gastrointestinal Pathology in the Older Adult...................................................... 271 Noam Harpaz, Hongfa Zhu, and Mohammad Raou Motility Disorders

Part VII 29 30 31

Dysphagia.................................................................................................................. 293 James C. Reynolds and Bassem R. George Gastroparesis in Older Adults ................................................................................ 301 Richard W. McCallum and Ashish Malhotra Esophageal Reux Disease and Its Complications................................................ 311 Missale Solomon and James C. Reynolds Signs and Symptoms

Part VIII 32

Abdominal Pain ........................................................................................................ 323 C.S. Pitchumoni and T.S. Dharmarajan

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33 34 35 36

Intestinal Gas............................................................................................................ 329 Debra R. Goldstein and C.S. Pitchumoni Constipation.............................................................................................................. 337 T.S. Dharmarajan, David Widjaja, and C.S. Pitchumoni Diarrhea .................................................................................................................... 351 Sita Chokhavatia and Arvind J. Trindade Upper and Lower Gastrointestinal Bleeding ......................................................... 363 C.S. Pitchumoni and Alexander Brun Hepato Biliary System and Pancreas

Part IX 37 38 39 40

Liver Function Tests and Interpretation................................................................ 375 Jacob Alexander and Kris V. Kowdley Viral Liver Diseases ................................................................................................. 383 Satheesh Nair and Jihad O. Arteh Tumors of the Liver ................................................................................................. 391 Satheesh Nair and Jihad O. Arteh Nonalcoholic Fatty Liver Disease (NAFLD) and Nonalcoholic Steatohepatitis (NASH)............................................................................................ 399 C.S. Pitchumoni Drug-Induced Liver Injury ..................................................................................... 409 Indira Donepudi, Hatef Massoumi, T.S. Dharmarajan, and C.S. Pitchumoni Gallbladder Disease ................................................................................................. 421 Rad M. Agrawal, Suzanne Morrissey, and Shyam Thakkar Acute Pancreatitis .................................................................................................... 429 C.S. Pitchumoni Chronic Pancreatitis ................................................................................................ 441 Gaurav Aggarwal and Suresh T. Chari Luminal Disorders

41 42 43 44

Part X 45 46 47 48 49 50 51 52

Oral Health in Older Adults ................................................................................... 451 Mary S. Haumschild and Barbara G. Hammaker Small Intestinal Bacterial Overgrowth Syndrome ................................................ 457 T.S. Dharmarajan and C.S. Pitchumoni Peptic Ulcer............................................................................................................... 463 Isidor Segal Irritable Bowel Syndrome ....................................................................................... 467 Eamonn M.M. Quigley Intestinal Ischemia ................................................................................................... 475 Hazar Michael and C.S. Pitchumoni Inammatory Bowel Disease ................................................................................... 483 Jeffrey Raphael Abergel and Kiron M. Das Non-IBD and Noninfectious Colitis ........................................................................ 493 Ole Haagen Nielson and Jakob Benedict Seidelin Celiac Disease ........................................................................................................... 501 C.S. Pitchumoni and Nancy Chen

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53 54 55 56 57

Diverticular Disease ................................................................................................. 511 C.S. Pitchumoni Clostridium difcile-Associated Diseases ................................................................ 519 C.S. Pitchumoni and T.S. Dharmarajan Gastrointestinal Infections ...................................................................................... 527 David V. Alcid Anal Incontinence .................................................................................................... 533 Sanjiv K. Patankar and Negar M. Salehomoum Rectal Prolapse ......................................................................................................... 541 Sanjiv K. Patankar and Rodolfo Pigalarga Neoplasms

Part XI 58

Colorectal Cancer Screening in the Older Adult: A Case-Based Approach .......................................................................................... 549 Brijen J. Shah and Sita Chokhavatia Gastrointestinal Polyps ............................................................................................ 559 Tamir Ben-Menachem Gastric Neoplasms ................................................................................................... 565 Philip Chang and Isidor Segal Esophageal Cancer................................................................................................... 571 Noah Kornblum Pancreatic Cancer .................................................................................................... 581 Gaurav Aggarwal and Suresh T. Chari Colorectal Cancer .................................................................................................... 587 Giridhar U. Adiga and Janice P. Dutcher Palliative Care

59 60 61 62 63

Part XII 64

Palliative Care of GI Issues at the End of Life ...................................................... 599 John M. Heath and Elizabeth Poplin Surgery

Part XIII 65 66

The Surgical Abdomen ............................................................................................ 607 Carlos A. Pelaez and Nanakram Agarwal Colostomy and Ileostomy Care ............................................................................... 615 Juan J. Omana and Nanakram Agarwal Systems Disorders

Part XIV 67 68 69 70

Gastrointestinal and Hepatic Manifestations of Systemic Diseases .................... 623 Ellen C. Ebert Abdominal Aortic Aneurysm .................................................................................. 631 T.S. Dharmarajan Rheumatological Manifestations of Gastrointestinal Disease .............................. 637 Nayan K. Kothari and Srilatha Kothandaraman Mucocutaneous Manifestations with Gastrointestinal Disease............................ 647 Robert A. Norman and Trupal Patel

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71 72

HIV Disease .............................................................................................................. 659 C.S. Pitchumoni and Alexander Brun Gastrointestinal Disorders in the Older Adult: The Psychiatrists Role ............................................................................................ 667 Alberto Cortes-Ladino

Index .................................................................................................................................. 671

Contributors

Jeffrey Raphael Abergel, MD Department of Medicine, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ, USA Giridhar U. Adiga, MD, FACP Department of Medical Oncology, Ephrata Cancer Center, Ephrata, PA, USA Nanakram Agarwal, MD, MPH, FRCS, FACS Department of Surgery, Monteore Medical Center (North Division), Bronx, NY, USA Gaurav Aggarwal, MBBS Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA Rad M. Agrawal, MD, FACP, FACG, AGAF, FASGE Allegheny General Hospital, Drexel University College of Medicine, Division of Gastroenterology, Pittsburgh, Pennsylvania, USA David V. Alcid, MD Department of Medicine, Saint Peters University Hospital, New Brunswick, NJ, USA Jacob Alexander, MBBS, MD, DM Division of Gastroenterology, University of Washington, Seattle, WA, USA Judith K. Amorosa, MD, FACR Department of Radiology, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA Krishna P. Aparanji, MD Division of Geriatrics, Monteore Medical Center (North Division), Bronx, NY, USA Jihad O. Arteh, MD Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, TN, USA Alexander Brun, MD Department of Medicine, Division of Gastroenterology, North Shore-Long Island Jewish Health System, New Hyde Park, NY, USA Philip Chang, MBBS, FRACP Gastrointestinal and Liver Unit, Prince of Wales Hospital, Sydney, NSW, Australia Suresh T. Chari, MD Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA Nancy Chen, MD Department of Gastroenterology, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA Sita Chokhavatia, MD Departments of Internal Medicine and Gastroenterology, Mount Sinai Hospital, New York, NY, USA

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Eugene C. Corbett, Jr, MD, FACP General Medicine, Geriatrics and Palliative Care, Department of Internal Medicine, University of Virginia, Charlottesville, VA, USA Alberto Cortes-Ladino, MD Department of Psychiatry, Monteore Medical Center (North Division), New York, NY, USA Kiron M. Das, MD, PhD Division of Gastroenterology and Hepatology, Department of Medicine, Crohns and Colitis Center of New Jersey, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ, USA Kumar Dharmarajan, MD, MBA Department of Medicine, Massachusetts General Hospital, Boston, MA, USA T.S. Dharmarajan, MD, FACP, AGSF Professor of Medicine, Associate Dean, New York Medical College, Valhalla, NY, USA Vice Chairman, Department of Medicine, Clinical Director, Division of Geriatrics, Program Director, Geriatric Medicine Fellowship Program, Monteore Medical Center (North Division), Bronx, NY, USA Indira Donepudi, MD Division of Gastroenterology, Monteore Medical Center (North Division), Bronx, NY, USA Janice P. Dutcher, MD Division of Hematology/Oncology, Department of Medicine, Continuum Cancer Centers, St. Lukes Roosevelt Hospital Center, New York, NY, USA Ellen C. Ebert, MD Department of Medicine, Robert Wood Johnson Medical School, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA Martin H. Floch, MD, MS, BA Yale Digestive Diseases, Yale New Haven Hospital, New Haven, CT, USA Bassem R. George, MD Department of Internal Medicine, Hahnemann University Hospital/ Drexel University College of Medicine, Philadelphia, PA, USA Fisseha Y. Ghidey, MD, MPH Department of Internal Medicine, Saint Peters University Hospital, New Brunswick, NJ, USA Neelam G. Gidwaney, MD Department of Internal Medicine, Robert Wood Johnson School of Medicine, New Brunswick, NJ, USA Debra R. Goldstein, MD, FACP Department of Internal Medicine, Saint Peters University, New Brunswick, NJ, USA Julia B. Greer, MD, MPH Division of Gastroenterology, Hepatology & Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA Srinivas Guptha Gunturu, MD Department of Medicine, Monteore Medical Center (North Division), Bronx, NY, USA Karen E. Hall, MD, PhD Department of Internal Medicine, University of Michigan Healthcare System, East Ann Arbor Health and Geriatric Center, Geriatric Clinic, Ann Arbor, MI, USA Barbara G. Hammaker, RDH, BASDH, MHS Department of Dental Hygiene, Broward College, Davie, FL, USA Noam Harpaz, MD, PhD Departments of Pathology and Medicine, Division of Gastroenterology, Mount Sinai School of Medicine, New York, NY, USA Mary Snider Haumschild, RDH, RN, MHSc, DrHS Department of Health Sciences, St. Petersburg College, Seminole, FL, USA

Contributors

xix

Ryan J. Haumschild, MBA, BS University of Florida College of Pharmacy, Shands Hospital, Gainesville, FL, USA John M. Heath, MD, AGSF Geriatric Services Director, Summit Medical Group, Berkeley Heights, NJ, USA Hilary I. Hertan, MD Department of Medicine, Division of Gastroenterology and Clinical Nutrition, Monteore Medical Center (North Division), Bronx, NY, USA Vishal Jain, MD Department of Gastroenterology and Hepatology, Penn State Hershey Medical Center, Hershey, PA, USA Sunil S. Jhangiani, MD, MBA, FACP, AGAF Division of Clinical Nutrition, and Gastroenterology & Department of Internal Medicine, Monteore Medical Center (North Division), Bronx, NY, USA Manie Juneja, MD Department of Internal Medicine, Georgetown University Hospital, Washington, DC, USA Noah Kornblum, MD Department of Oncology, Monteore Medical Center (North Division), Bronx, NY, USA Srilatha Kothandaraman, MD Department of Medicine, Saint Peters University Hospital; Drexel University College of Medicine, New Brunswick, NJ, USA Nayan K. Kothari, MD, FACP Department of Medicine, Saint Peters University Hospital; Drexel University College of Medicine, New Brunswick, NJ, USA Kris V. Kowdley, MD, FACP, FACG, FASGE, AGAF Department of Gastroenterology, Virginia Mason Medical Center, Seattle, WA, USA Frank J. Lukens, MD Health Science Center at Houston, The University of Texas, Houston, TX, USA Ashish Malhotra, MD Department of Gastroenterology and Hepatology, Seton Hall University of Health and Medical Sciences, Paterson, NJ, USA Hatef Massoumi, MD Department of Medicine, Division of Hepatology, Monteore Medical Center, Bronx, NY, USA Fernanda Samara Mazzariol, MD Department of Radiology, Monteore Medical Center, Bronx, NY, USA Richard W. McCallum, MD, FACP, FRACP, (AUST), FACC Department of Internal Medicine, Texas Tech University Health Sciences Center, Paul L. Foster School of Medicine, El Paso, TX, USA Tamir Ben-Menachem, MD, MS Department of Gastroenterology, Robert Wood Johnson Medical School, Summit Medical Group, Berkeley Heights, NJ, USA Hazar Michael, MD Department of Medicine, UMDNJ-RWJMS, New Brunswick, NJ, USA Kenneth L. Minaker, MD Department of Medicine, Massachusetts General Hospital, Boston, MA, USA Suzanne Morrissey, MD Department of Gastroenterology, Allegheny General Hospital, West Penn Health System, Pittsburgh, PA, USA Satheesh Nair, MD, MBBS Transplant Department, Methodist University Hospital, Memphis, TN, USA Haq Nawaz, MD Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA

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Contributors

Ole Haagen Nielson, MD, DMSc Department of Gastroenterology D112, Herlev Hospital, Herlev, Denmark Robert A. Norman, DO, MPH, MBA Department of Dermatology, Nova Southeastern College of Medicine, Tampa, FL, USA Stephen J.D OKeefe, MD, MSc Department of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA Juan J. Omana, MD Department of Surgery, Monteore Medical Center (North Division), Bronx, NY, USA Noelle OShea, DO Division of Gastroenterology, Hepatology and Nutrition, The University of Texas Health Science Center at Houston, Houston, TX, USA Sanjiv K. Patankar, MD, FACS, FRCS (Edinburgh), FASCRS Division of Colo-rectal Surgery, Department of Surgery, Saint Peters University Hospital, East Brunswick, NJ, USA Trupal Patel, BS Dermatology Healthcare, LLC, Tampa, FL, USA Carlos A. Pelaez, MD Department of Surgery, Monteore Medical Center (North Division), Bronx, NY, USA Rodolfo Pigalarga, MD Department of General Surgery, Robert Wood Johnson University Hospital/UMDNJ, New Brunswick, NJ, USA C.S. Pitchumoni, MD, MPH, FRCP(C), MACP, MACG, AGAF Clinical Professor of Medicine, Robert Wood Johnson School of Medicine, Drexel University School of Medicine, Adjunct Professor of Medicine, New York Medical College, Valhalla, NJ, USA Chief, Gastroenterology, Hepatology and Nutrition, Saint Peters University Hospital, New Brunswick, NJ, USA Elizabeth Poplin, MD The Cancer Institute of New Jersey, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA Eamonn M.M Quigley, MD, FRCP, FACP, FACG, FRCPI Department of Medicine, Alimentary Pharmabiotic Centre University College Cork, Cork University Hospital, Cork, Ireland Mohammad Raou, MD Department of Pathology, Mount Sinai School of Medicine, New York, NY, USA James C. Reynolds, MD Department of Medicine, Drexel University College of Medicinef/ Hahnemann University Hospital, Philadelphia, PA, USA Negar M. Salehomoum, MD Department of General Surgery, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ, USA Isidor Segal, FRCP(UK), FRACP, PhD, AGAF, Master WGO Department of Gastroenterology and Hepatology, Prince of Wales Hospital, Randwick, Sydney, NSW, Australia Jakob Benedict Seidelin, MD, PhD Department of Gastroenterology D112, Herlev Hospital, Herlev, Denmark Brijen J. Shah, MD Department of Medicine and The Brookdale Department of Gastroenterology, The Henry D. Janowitz Division of Gastroenterology, Mount Sinai Medical Center, New York, NY, USA Amit Sohagia, MD Department of Gastroenterology, Monteore Medical Center (North Division), Bronx, NY, USA

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Missale Solomon, MD Department of Gastroenterology and Hepatology, Hahnemann University Hospital, Philadelphia, PA, USA Sirakarn Tejavanija, MD, MS Department of Endocrinology and Clinical Nutrition, Phramongkutklao Army Hospital and College of Medicine, Bangkok, Thailand Shyam Thakkar, MD Department of Gastroenterology, Allegheny General Hospital, West Penn Health System, Pittsburgh, PA, USA Arvind J. Trindade, MD Department of Internal Medicine, Mount Sinai Hospital, New York, NY, USA David Widjaja, MD Department of Medicine, Division of Gastroenterology, Bronx Lebanon Hospital Center, Albert Einstein College of Medicine, Bronx, NY, USA Dhiraj Yadav, MD, MPH Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA Hongfa Zhu, MD, PhD Department of Pathology, Mount Sinai School of Medicine, New York, NY, USA