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Gastroenterology and Hepatology High Value Care Recommendations The American College of Physicians, in collaboration with e Patients with acute pancreatitis should undergo transab- multiple other organizations, is engaged in a worldwide dominal ultrasonography rather than CT for evaluation of initiative to promote the practice of High Value Care biliary disease. (HVC). The goals of the HVC initiative are to improve ¢ Routine use of antibiotics is not warranted in acute pan- health care outcomes by providing care of proven benefit creatitis (see Item 12). and reducing costs by avoiding unnecessary and even Patients with acute pancreatitis should resume feeding harmful interventions. The initiative comprises several when pain improves and any nausea or vomiting subsides; programs that integrate the important concept of health oral feeding is preferred (see Item 16). care value (balancing clinical benefit with costs and Evaluation for centrally mediated pain syndrome requires harms) for a given intervention into a broad range of a detailed medical and psychosocial history and physical educational materials to address the needs of trainees, examination, with limited laboratory testing. practicing physicians, and patients. Acute diverticulitis is often a clinical diagnosis, usually not requiring abdominal imaging unless an alternative HVC content has been integrated into MKSAP 19 in several diagnosis or complicated disease is suspected. important ways. MKSAP 19 includes HVC-identified key Lactase deficiency can be diagnosed on the basis of points in the text, HVC-focused multiple-choice questions, improvement after exclusion of dietary lactose or admin- and, in MKSAP Digital, an HVC custom quiz. From the text istration of lactase enzymes with meals (see Item 37). and questions, we have generated the following list of HVC e The most common cause of recurrent celiac disease recommendations that meet the definition below of high symptoms is gluten exposure (see Item 45). value care and bring us closer to our goal of improving Many drugs can cause chronic diarrhea; discontinuing a patient outcomes while conserving finite resources. potential culprit drug may relieve symptoms and obviate High Value Care Recommendation: A recommendation to the need for further diagnostic testing (see Item 59). choose diagnostic and management strategies for patients Antibiotics are not recommended for mild traveler’s in specific clinical situations that balance clinical benefit diarrhea (see Item 86). with cost and harms with the goal of improving patient ¢ Irritable bowel syndrome is a common cause of diarrhea outcomes. and can be diagnosed on clinical grounds, including history and physical examination (see Item 22). Below are the High Value Care Recommendations for the e Empiric antibiotic therapy with monitoring for improve- Gastroenterology and Hepatology section of MKSAP 19. ment in symptoms may be reasonable in patients with a e In patients with symptoms of gastroesophageal reflux high probability of small intestinal bacterial overgrowth disease but without alarm features, an empiric trial of a (see Item 67). proton pump inhibitor is the initial management. e Elastography is a noninvasive imaging technique that ¢ Candida esophagitis can be diagnosed clinically in assesses liver stiffness as a measure of fibrosis and may patients with dysphagia and odynophagia, immunosup- avoid biopsy. pression, and findings of oral thrush (see Item 89). e Asymptomatic hepatic cysts are benign and require no e PPI therapy should be used at the lowest dose needed to follow-up. control gastroesophageal reflux symptoms and discontin- ¢ Focal nodular hyperplasia does not have malignant ued if there is no appropriate indication (see Item 44). potential or a risk for bleeding and does not require e For patients with dyspepsia, routine upper endoscopy to follow-up. exclude malignancy is reserved for patients age 60 years ¢ No information indicates that the addition of o-fetoprotein and older. (AFP) to ultrasonography screening for hepatocellular e In countries with a low incidence of gastric cancer, such carcinoma leads to improved survival; therefore, surveil- as the United States, screening for gastric cancer should lance using ultrasonography may be performed with or be reserved for patients with genetic cancer syndromes. without AFP measurement every 6 months (see Item 30). e For patients with dyspepsia, a “test and treat” strategy for e The mainstay of management of nonalcoholic fatty liver Helicobacter pylori infection is recommended (see Item 70). disease is weight loss (see Item 35). e Routine repeat upper endoscopy for gastric ulcer is not e Management of chronic pain in patients with chronic recommended (see Item 73). liver disease should always include physical therapy

The American College of Physicians, in collaboration with e Patients with acute pancreatitis should undergo transab- multiple other organizations, is engaged in a worldwide dominal ultrasonography rather than CT for evaluation of initiative to promote the practice of High Value Care biliary disease. (HVC). The goals of the HVC initiative are to improve ¢ Routine use of antibiotics is not warranted in acute pan- health care outcomes by providing care of proven benefit creatitis (see Item 12). and reducing costs by avoiding unnecessary and even Patients with acute pancreatitis should resume feeding harmful interventions. The initiative comprises several when pain improves and any nausea or vomiting subsides; programs that integrate the important concept of health oral feeding is preferred (see Item 16). care value (balancing clinical benefit with costs and Evaluation for centrally mediated pain syndrome requires harms) for a given intervention into a broad range of a detailed medical and psychosocial history and physical educational materials to address the needs of trainees, examination, with limited laboratory testing. practicing physicians, and patients. Acute diverticulitis is often a clinical diagnosis, usually not requiring abdominal imaging unless an alternative HVC content has been integrated into MKSAP 19 in several diagnosis or complicated disease is suspected. important ways. MKSAP 19 includes HVC-identified key Lactase deficiency can be diagnosed on the basis of points in the text, HVC-focused multiple-choice questions, improvement after exclusion of dietary lactose or admin- and, in MKSAP Digital, an HVC custom quiz. From the text istration of lactase enzymes with meals (see Item 37). and questions, we have generated the following list of HVC e The most common cause of recurrent celiac disease recommendations that meet the definition below of high symptoms is gluten exposure (see Item 45). value care and bring us closer to our goal of improving Many drugs can cause chronic diarrhea; discontinuing a patient outcomes while conserving finite resources. potential culprit drug may relieve symptoms and obviate High Value Care Recommendation: A recommendation to the need for further diagnostic testing (see Item 59). choose diagnostic and management strategies for patients Antibiotics are not recommended for mild traveler’s in specific clinical situations that balance clinical benefit diarrhea (see Item 86). with cost and harms with the goal of improving patient ¢ Irritable bowel syndrome is a common cause of diarrhea outcomes. and can be diagnosed on clinical grounds, including history and physical examination (see Item 22). Below are the High Value Care Recommendations for the e Empiric antibiotic therapy with monitoring for improve- Gastroenterology and Hepatology section of MKSAP 19. ment in symptoms may be reasonable in patients with a e In patients with symptoms of gastroesophageal reflux high probability of small intestinal bacterial overgrowth disease but without alarm features, an empiric trial of a (see Item 67). proton pump inhibitor is the initial management. e Elastography is a noninvasive imaging technique that ¢ Candida esophagitis can be diagnosed clinically in assesses liver stiffness as a measure of fibrosis and may patients with dysphagia and odynophagia, immunosup- avoid biopsy. pression, and findings of oral thrush (see Item 89). e Asymptomatic hepatic cysts are benign and require no e PPI therapy should be used at the lowest dose needed to follow-up. control gastroesophageal reflux symptoms and discontin- ¢ Focal nodular hyperplasia does not have malignant ued if there is no appropriate indication (see Item 44). potential or a risk for bleeding and does not require e For patients with dyspepsia, routine upper endoscopy to follow-up. exclude malignancy is reserved for patients age 60 years ¢ No information indicates that the addition of o-fetoprotein and older. (AFP) to ultrasonography screening for hepatocellular e In countries with a low incidence of gastric cancer, such carcinoma leads to improved survival; therefore, surveil- as the United States, screening for gastric cancer should lance using ultrasonography may be performed with or be reserved for patients with genetic cancer syndromes. without AFP measurement every 6 months (see Item 30). e For patients with dyspepsia, a “test and treat” strategy for e The mainstay of management of nonalcoholic fatty liver Helicobacter pylori infection is recommended (see Item 70). disease is weight loss (see Item 35). e Routine repeat upper endoscopy for gastric ulcer is not e Management of chronic pain in patients with chronic recommended (see Item 73). liver disease should always include physical therapy xiii

because it will not exacerbate the manifestations of Patients with peptic ulcer disease and low-risk stigmata chronic liver disease (see Item 82). can be fed within 24 hours of endoscopy, receive ¢ Patients in the immune control phase of chronic HBV once-daily oral PPI therapy, and be discharged from the infection, also known as inactive chronic HBV infection, hospital. generally do not require treatment (see Item 4). In uncomplicated asymptomatic patients with iron defi- e Uncomplicated diverticulitis is treated with oral antibiot- ciency anemia and negative bidirectional endoscopy, a ics (ciprofloxacin or metronidazole) and a liquid diet (see trial of initial iron supplementation over the routine use of Item 6). video capsule endoscopy is conditionally suggested by the e Incidental gallstones do not typically cause symptoms, American Gastroenterological Association (see Item 60). and prophylactic cholecystectomy and other treatments The risk for rebleeding in patients with high-risk ulcers are generally not recommended (see Item 78). that are successfully treated endoscopically is similar for e In acute cholecystitis, cholecystectomy during the initial patients who receive twice-daily intravenous PPI and hospitalization is associated with improved clinical out- those who receive continuous PPI infusion; twice-daily comes and lower costs compared with delayed cholecys- PPI is preferable given the similar clinical efficacy and tectomy (see Item 74). lower cost (see Item 88). e For patients with mild gallstone pancreatitis, same-ad- When there is no evidence that a patient’s requested mission cholecystectomy reduces rates of gallstone-re- diagnostic or therapeutic intervention will provide clin- lated complications compared with cholecystectomy 25 ical benefit, physicians are not obligated to provide the to 30 days after hospital discharge (see Item 96). service (see Item 58). xiv