Gastroenterology and the Rise of Private Equity Investments

Posted on by
Reply

TA Brenner et al. Clin Gastroenterol Hepatol 2026: 24: 7-9. Geodemographic Trends in Private Equity Acquisitions of US Gastroenterology Practices: An Analysis of Transactions From 2013 to 2023

An excerpt:

“The combination of high-volume procedures, strong ancillary revenue streams, and opportunities for outpatient consolidation has made gastroenterology a prime target for PE-backed investment. For many gastroenterologists, this trend is no longer theoretical—it is local, visible, and shaping the landscape of everyday practice.”

“Between 2013 and 2023, PE firms acquired 114 outpatient gastroenterology practices, encompassing 1169 clinical sites nationwide…That includes 854 clinics, 266 endoscopy centers, and 49 infusion centers. Collectively, these sites employed approximately 2675 physicians and advanced practice providers. In total, around 14% of all gastroenterology clinical sites nationwide are now affiliated with PE-backed platforms.”

 (A) Trend in private equity acquisitions of gastroenterology practices (red)
and gastroenterology clinical sites (blue) by year.

“PE firms are less likely to invest in gastroenterology practices located in the poorest communities… Practices in zip codes with the lowest income levels were about 60% less likely to be acquired than those in wealthier areas (aRR, 0.37; 95% CI, 0.31–0.45; P < .001)…PE firms tend to prioritize markets with strong commercial payer mixes and higher rates of elective procedures, steering clear of areas with high Medicaid penetration or large numbers of uninsured patients.”

Key Points:

  • “First, consolidation is accelerating…Even if you are not interested in selling, you may need to compete with PE-backed groups that have more capital, better tech infrastructure, and stronger payer contracts”
  • “Second, staying independent may become more difficult. As regional consolidation increases, remaining unaffiliated could put independent practices at a disadvantage. PE-backed platforms often negotiate better rates with commercial insurers and have the scale to invest in centralized billing, marketing, and compliance.”
  • “Third…If PE firms avoid lower-income or rural areas, gastroenterology access could become more uneven and more challenging to sustain in underserved regions.”
  • “Studies in other specialties suggest that practices owned by PE firms often face changes in staffing, autonomy, and productivity expectations. Physicians may experience higher pressure to perform more procedures, see more patients, or adopt system-wide workflows they did not design.”

My take: PE acquisitions are affecting broad areas of healthcare. However, they do not seem to result in improvement in patient care or physician satisfaction.

Related blog posts:

Updated Data on PPI Effectiveness For Eosinophilic Esophagitis

Posted on by
Reply

AJ Lucendo et al. Clin Gastroenterol Hepatol 2025; 23: 2115-2127. Proton Pump Inhibitors for Inducing and Maintaining Remission in Eosinophilic Esophagitis: An Updated Systematic Review and Meta-Analysis

Background/Methods: This systematic review aimed to update the response/remission rates of PPI therapy for eosinophilic esophagitis. Compared to review in 2016, the current review covers a 10-fold increase in population (from 619 to 7304 patients), with a more balanced distribution between children (41%) and adults, and with a geographical representation from several continents.

Key findings:

  • PPI therapy led to clinical response in 65% (95% confidence interval [CI], 57.2–72.4)) and histological remission (<15 eos/hpf) in 45.4% (95% CI, 41.6%–49.3%) of patients, without differences between children and adults (41.4% vs 48%; P = .17)
  • Overall, 34.1% (95% CI, 27.9%–40.5%) achieved <5 eosinophils per high-power field
  • Maintenance half-doses led to sustained histological remission in 68.2% (95% CI, 63.7%–72.6%) of patients
  • Clinical and histological remission (<15 eos/hpf) was achieved in 45% of patients
  • Histological remission was significantly higher with double PPI doses compared with standard (51.7% vs 28.3%; P < .005)

In the discussion, it was noted that Japanese cohorts had a better response to PPI therapy with a histological remission (67.9%). This could be related to more favorable metabolism of PPI. “CYP2C19∗17 haplotype (related to ultrarapid and rapid PPI metabolizers), is the least prevalent (<3%) in patients with Asian ancestry.”

My take: This study reinforces previous data showing a 40-50% remission rate with PPI therapy for EoE. Twice a day PPI therapy is significantly more effective than once a day.

Related blog posts:

#5000: Simple Rule for Deciding When pH Impedance Testing Should Be Done While on Therapy

Posted on by
Reply

Editor’s note: This is the 5000th post on this blog! The first post was on December 7th, 2011.

Iguazu Falls

CP Gyawali et al. Clin Gastroenterol Hepatol 2025; 23: 2459-2467. Open Access! pH Impedance Monitoring on Proton Pump Inhibitor Therapy Impacts Management Decisions in Proven GERD but Not in Unproven GERD

Methods: Prospective 2-center study enrolled adult patients (n=79) with typical reflux symptoms with incomplete PPI response; they were studied both off PPI (wireless pH monitoring) and on PPI (pH-impedance monitoring)

Key findings:

  •  In 60 patients with proven GERD off-PPI, 56.7% had no ongoing GERD on PPI (despite reflux symptoms)
  • In unproven GERD, pH-impedance monitoring on acid suppressive therapy is unable to differentiate non-GERD symptoms from controlled GERD in the majority of patients, or identify patients who could benefit from discontinuation of acid suppression

Discussion points:

  • “Only a small proportion of PPI nonresponders have true GERD, and most have either no GERD or overlap between inconclusive GERD and a non-GERD process such as an esophageal disorder of gut-brain interaction (E-DGBI).10,11“
  • “On-therapy pH-impedance monitoring can identify refractory GERD in patients with previously proven GERD.”
  • “Definitive GERD evidence and persisting symptoms despite optimized PPI therapy is an indication for escalation of management.20… potassium competitive acid blockers provide better healing of advanced grade esophagitis21 as well as faster symptom response in nonerosive reflux disease,22,23 and could be an option”

My take:

  1. Simple rule: Only perform on-therapy pH-impedance monitoring in patients with proven GERD
  2. Many patients with GERD symptoms do not have GERD (see posts below)
  3. In patients with documented GERD, on therapy pH monitoring can be helpful in proving refractory GERD which may benefit from alternative treatments

Related blog posts:

Nahuel Huapi Lake (near Bariloche, Argentina)

Etrasimod for Ulcerative Colitis (2026)

Posted on by
Reply

AJ Yarur et al. Clinical Gastroenterology and Hepatology 2026; 24: 210 – 220. Open Access! Efficacy of Etrasimod in Ulcerative Colitis: Analysis of ELEVATE UC 52 and ELEVATE UC 12 by Baseline Endoscopic Severity.

Methods: Efficacy end points were evaluated at Weeks 12 (pooled population) and 52 (ELEVATE UC 52)

Key findings:

  • Clinical remission in the moderate group compared to placebo: Week 12: 38.3% vs 17.9%; Week 52: 36.5% vs 14.3%
  • Clinical remission in the severe group compared to placebo: Week 12: 18.2% vs 6.1%; Week 52: 29.4% vs 3.4%
  • “Our findings were consistent with those for other UC treatments…with efficacy improvements generally being greater among patients who were naive rather than experienced with biologics and/or JAKi.12–17“

My take: Etrasimod demonstrated significant induction and maintenance efficacy over placebo in both moderate and severe endoscopic disease. Its role remains limited as there are other treatments with improved likelihood of response, especially in those with prior advanced therapies. However, it is notable that recent AGA guidelines promote etrasimod as one of the higher efficacy agents in patients naive to advanced therapies.

Related blog posts:

Increased Mortality with Achalasia

Posted on by
Reply

A Forss et al. Clin Gastroenterol Hepatol 2025: 23: 2468-2476. Open Access! All-cause and Cause-specific Mortality in Achalasia: A Nationwide Matched Cohort Study

Methods: This study was a nationwide, population-based, matched cohort study using the Epidemiology Strengthened by Histopathology Reports in Sweden (ESPRESSO) cohort which included all adults in Sweden with incident achalasia (n = 704; 1969–2017; follow-up until December 31, 2021) without any other prior esophageal conditions. Individuals with achalasia were matched by age, sex, birth year, and county to up to 5 reference individuals (n = 3348) from the general population. The median follow-up was 9.1 years. Medians age in the study was 60 years.

Key findings:

  • There were 270 deaths in individuals with achalasia, and 1023 in reference individuals (IR, 69.4 vs 51.9/1000 person-years)
  • Thus, there was a 42% increase in the risk of death. This translated into 1 extra death per every 6 individuals with achalasia followed for 10 years
  • Risk increases were seen for death from any cancer (aHR, 1.65), esophageal cancer (aHR, 23.19), and respiratory disease (aHR, 2.22)

Discussion point: “The sibling comparison (aHR for all-cause mortality, 1.78; 95% CI, 1.13–2.81) confirmed our findings in the main analysis (aHR, 1.42; 95% CI, 1.21–1.65). The similar risk estimates suggest that shared early-life exposures do not play any major role for mortality in achalasia. In all, we are confident that the observed elevated mortality is unlikely to be fully explained by environmental exposures or comorbidities, because the risk estimates remained largely unchanged in the sibling comparison as well as after adjustment for a wide range of comorbidities (through CCI).”

My take: This study is in agreement with others which have sown that achalasia is associated with an increased mortality risk.

Related blog posts:

Big Study: Total Pancreatectomy with Islet Autotransplantation (TPIAT) for Chronic Pancreatitis

Posted on by
Reply

T Guru et al. Gastroenterology 2025: 169:1499 – 1509. Total Pancreatectomy With Islet Autotransplantation for Chronic Pancreatitis

This prospective multicenter study included 384 patients with a mean age of 30 years (34% pediatric).

Key findings:

  • Daily abdominal pain decreased from 65% to 23%, whereas the mean pain score decreased from 4.9 (SD, 2.3) to 2.3 (SD, 2.5; both P < .001)
  • Opioid use decreased (assessed over a 14-day interval) from 61% before to 24% at 1 year after TPIAT (P < .001)
  • Improved physical and mental health: Physical component summary and mental component summary scores improved by ≥10 points in 58% and 35%, respectively
  • Mean hemoglobin A1c was 7% (SD, 1.9%) with 20% insulin independent at 1 year
  • Young age was associated with better outcomes, whereas duration and etiology of disease did not predict response to TPIAT

In their discussion, the authors note that it had been “widely hypothesized that after several years of pain, mechanism shift to solely neuropathic pain, such that surgery would be unlikely to offer benefit. Our results suggest this is not true.”

My take: This study provides robust data supporting TPIAT as average pain scores declined by more than 50%, the need for opioid analgesics decreased substantially, and mental health/physical health/QOL all improved. Most maintained glycemic control.

Related blog posts:

Humor (from 2009): YouTube Link: Brain Surgeon – That Mitchell & Webb Look (2:09 min)

    Lower Expectations for Outcomes After Botox for Retrograde Cricopharyngeus Dysfunction (aka Abelchia)

    Posted on by
    Reply

    K Raymenants et al. Clin Gastroenterol Hepatol 2026; 24: 81-91. Diagnosis of Retrograde Cricopharyngeus Dysfunction Using High Resolution Impedance Manometry and Comparison With Control Subjects

    Methods: Retrospective analysis of High Resolution Impedance Manometry
    (HRiM) with belch provocation was performed between May 2021 and April 2024 in 55 patients with R-CPD, 30 control patients, and 15 healthy volunteers. Age of patients with R-CPD was 22-35 years.

    Key findings:

    • During belching, we saw higher UES pressures in R-CPD patients vs controls, leading to incomplete air clearance and air oscillating in the esophagus (P < .0001)
    •  After BT injection, median UES pressures during belching decreased (56 vs 3 mmHg), and air clearance improved (P < .0001)
    • A maximum UES pressure during belching >31 mmHg adequately discriminated patients from controls
    • Interestingly, the authors did not include one of the major findings in their abstract: “Symptom improvement of at least 50% was present in 57% of patients, which is lower than reported up to now”
    • R-CPD patients had inability to belch in 100%, gurgling chest noises in 100%, bloating in 92%, chest pain in 67%, nausea in 59%, and heartburn (at least weekly) in 65%

    My take: Recognition of this treatable disorder is important. However, the lower improvement rate in this study is useful for counseling patients. My suspicion is that this finding likely reflects more widespread results as initial studies could have more selection or reporting bias.

    Related blog posts:

    Proactive Drug Monitoring for Crohn’s Disease in Pediatrics

    Posted on by
    Reply

    B Kang et al. Clinical Gastroenterology and Hepatology; 2026: 24: 201 – 209. Proactive Drug Monitoring Versus Clinically Based Dosing for Endoscopic Healing in Pediatric Crohn’s Disease Receiving Infliximab

    Methods: This was a non-blinded, randomized controlled trial of 112 biologic-naïve children with CD who had responded to IFX induction treatment at 4 centers in South Korea between July 2017 and November 2020. Patients were randomly assigned to receive dosing based on proactive TDM (proactive arm) or clinically based dosing (clinical arm). The primary endpoint was endoscopic healing (EH) at week 54.

    During the maintenance phase, patients received IFX 5 mg/kg every 8 weeks. In the proactive arm, treatment was intensified (shortening interval by 2- to 4-weeks) if trough level was less than 6 mcg/mL.

    Key findings:

    Sustained corticosteroid-free clinical remission (SCFCR) 

    Discussion Points:

    • “Our findings provide evidence that the proactive strategy resulted in increased EH rates and had a positive impact on SCFCR, biochemical remission, and FC, which serve as surrogate markers of EH.”
    • “The PAILOT trial, the only prospective study on proactive TDM in pediatric patients with CD, demonstrated that proactive TDM with adalimumab resulted in higher SCFCR rates than reactive TDM (82% vs 46%; P < .001), consistent with our findings.8“
    • “In our study, IMM [immunomodulator] modulation was performed in conjunction with proactive TDM, which may explain why no difference was observed in ADA development (proactive arm, 31.4% vs clinical arm, 28.6%. Proactive TDM has been confirmed to reduce the development of ADAs, and the concept of “optimized monotherapy” based on the view that proactive TDM effectively guides IMM withdrawal in combination therapy has been well-described.30 …in our institution, IMMs are discontinued as soon as possible after 1 year of combination therapy if adequate TDM is maintained.31“

    My take: This study shows that proactive TDM is superior to clinical-based dosing. The findings may have been less pronounced if higher baseline doses of IFX were used. It is well-recognized that “standard” IFX (5 mg/kg/dose every 8 weeks) is usually insufficient in pediatric patients.

    Related blog posts:

    Natural History of Varices in Children

    Posted on by
    Reply

    O Ackermann et al. Gastroenterol 2026; 170: 188-198. The Natural History of Gastroesophageal Varices in Children With Portal Hypertension

    Methods: Retrospective review of 1586 children with portal hypertension. 590 had two or more upper endoscopies (403 with biliary atresia).

    “For the purpose of this study, and based on our previous experience in children,8,11 the endoscopic pattern associated with a high risk of bleeding (ie., HRV) included grade 3 esophageal varices as well as grade 2 esophageal varices with red color signs or gastric varices (cardia), or both.” 

    The authors developed a HRV [high risk of varices] score as a composite index calculated as follows: 1 point for grade 1 esophageal varices, 2 points for grade 2 varices, 3 points for grade 3 varices, and 1 point each for the presence of red color signs or GOV1 (HRV score range, 0–5). High-risk varices had an HRV score of 3 to 5.

    Key findings:

    • Worsening of the endoscopic pattern occurred in 58% of children over a mean 4-year interval
    • 5- and 10-year probabilities of HRV emergence in initially HRV-negative children were 36% and 54%, respectively
    • Infants with biliary atresia are at particularly high risk with correlation to the degree of cholestasis (see below)
    • Platelet count less than 150,000 as an indicator of HRV was mainly useful in older children. “A platelet count of ≥150,000/mm3 was recorded in 205 of the 629 children (32%) with HRV. Moreover, there was a decrease with age in the proportion of children with HRV and a platelet count of ≥150,000/mm3, falling from 62% in children aged <12 months to 2% in patients aged >10 year.” 16% of children 6-8 yrs, 12% of children 8-10 years of age with HRV had platelet count ≥150,000/mm3
    • “Gastrointestinal bleeding was recorded in 36 of 947 children (3.8%) who did not have HRV at their last endoscopy and in 270 of the 359 children (75%) with HRV at their last endoscopy who did not undergo endoscopic or surgical primary prophylaxis of bleeding.”
    Bilirubin of 100 micoMol is equivalent to 5.8 mg/dL and 17.1 is eqivalent to 1 mg/dL

    Discussion Points:

    • Variceal progression was much faster in infants and is  is likely due to the severity of cholestasis and its impact on portal hypertension.
    • “It is notable that children with Alagille syndrome and those with genetic cholestasis with normal GGT have a lower rate of variceal progression and a lower mean HRV score than children with biliary atresia, despite comparably high levels of bilirubin. This suggests that different mechanisms of cholestasis … may have distinct consequences on intrahepatic portal vein branches resulting in varying degrees of portal hypertension.”
    • “In children with biliary atresia aged <12 months, grade 2 esophageal varices without red color signs or GOV1 (HRV score of 2) should be considered an indication for endoscopic primary prophylaxis.”
    • “Because the efficacy and safety of β-blockers have not been established in children, we suggest that this pattern—grade 1 varices with red color signs or GOV1—should prompt early repeat endoscopy to detect HRV in a timely manner…this repeat endoscopy could be recommended 6 months after the previous one.”
    • Limitations: High proportion of children with biliary atresia (limits conclusions with other disorders), and retrospective study since 1990
    • “Pending the results of future studies, the detection of palpable splenomegaly remains a simple and practical criterion for initiating screening endoscopy in children with portal hypertension”

    My take: This is a very useful study providing important data to help improve decision-making in children with portal hypertension.

    Related blog posts:

    Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

    Calprotectin Correlates with Disease Extent and Mucosal Healing in Ulcerative Colitis

    Posted on by
    Reply

    O Steinsbo et al. Am J Gastrolenterol 2025. 120: 2623-2631. Open Access! Fecal Calprotectin Correlates With Disease Extent but Remains a Reliable Marker of Mucosal Healing in Ulcerative Colitis. Thanks to Ben Gold for this reference.

    This single-center observational study (n=254) examined the correlation between fecal calprotectin (FC) levels with both disease extent and mucosal healing in ulcerative colitis. Mucosal healing was rated by the Mayo Endoscopic Score (MES).

    Key findings:

    • Disease extent: FC levels were significantly lower in proctitis (440 mg/kg) as compared with left-sided colitis (840 mg/kg) or pancolitis (1,690 mg/kg)
    • Mucosal healing: In MES ≤1, FC levels were significantly lower in proctitis (24) compared to left-sided colitis (40) or pancolitis (85)

    My take: Fecal calprotectin levels are clearly affected by the extent of disease involvement. However, the increase in calprotectin values associated with disease activity was significantly larger than the differences attributed to disease extent.

    Related blog posts: