Antroduodenal Dysmotility in Hypermobility Disorders and Ehlers-Danlos Syndrome

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KWE Sweerts et al. Alimentary Pharmacology & Therapeutics, 2025; 61:702–705. Open Access! Analysis of Antroduodenal Motility in Patients With Hypermobility Spectrum Disorders/Hypermobile Ehlers–Danlos Syndrome

Background: Hypermobility spectrum disorders (HSD) and hypermobility Ehlers–Danlos syndrome (hEDS) are frequently associated with gastrointestinal symptoms, although the underlying mechanisms remain unclear. Since recruitment occurred before the 2017 criteria for hEDS were established, it was not possible to distinguish between HSD and hEDS. 

Methods: Retrospective review of all patients (>18 yrs) referred t for gastrointestinal motility evaluation and undergoing ADM were consecutively included from 2009 to 2023. This included 239 patients (50 HSD/hEDS and 189 non-HSD/hEDS). The HSD/hEDS group showed a lower BMI and higher use of enteral feeding than the control group (p < 0.001 and p = 0.026, respectively). This group was also younger, with a mean age of 30.4 ± 11.1 years versus 45.3 ± 15.4 years (p < 0.001).

Key findings:

  • The prevalence of antroduodenal dysmotility was not different between both groups, but enteric dysmotility was less common in the HSD/hEDS group (13% vs. 34%, p = 0.006).
  • There were similar percentages of delayed gastric emptying than non-HSD/hEDS patients; delayed gastric emptying was highly prevalent in both groups, 85% in patients with HSD/hEDS and 94% in non-HSD/hEDS patients
  • There were no differences in predominant symptoms between patients with and without HSD/hEDS.

In the discussion, the authors note that the lower rate of dysmotility combined with higher rates of enteral nutrition indicate that “factors like visceral hypersensitivity and autonomic function could be relevant in this context.”

My take: Most patients at this referral center had delayed gastric emptying. However, Ehlers-Danlos patients, in fact, had lower rates of enteric dysmotility.

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Grand Palace, Bangkok

MASH Treatment: Curcumin Shows Promising Results

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G Musso et al. Hepatology 2025; 81: 560-575. Effect of phospholipid curcumin Meriva on liver histology and kidney disease in nonalcoholic steatohepatitis: A randomized, double-blind, placebo-controlled trial

“Let food be thy medicine” is a well-known phrase usually attributed to Hippocrates (though it is unclear if he said this). Regardless, this study indicates that added curcumin in the diet could be beneficial for steatotic liver disease.

Methods: In this double-blind trial, 52 patients with biopsy-proven NASH (71% with stage ≥F2 fibrosis, 58% with stage A2-G2/A2-G3a chronic kidney disease) were randomized 1:1 to receive Meriva 2 g/d (1 g BID) or placebo for 72 weeks. Meriva is a formulation of curcumin extract with phospholipids that has improved oral bioavailability of curcumin metabolites.

Key findings:

  • Sixteen (62%) patients on Meriva (curcumin) versus 3 (12%) patients on placebo had NASH resolution (RR = 5.33)
  • hirteen (50%) patients on Meriva versus 2 (8%) patients on placebo had ≥1 stage fibrosis improvement (RR = 6.50)
  • Eleven (42%) patients on Meriva versus 0 (0%) on placebo had regression of significant liver fibrosis (RR = 18.01)
  • Thirteen (50%) patients on Meriva versus 0 (0%) on placebo had chronic kidney disease regression (RR = 10.71)
  • Compared with placebo, Meriva improved eGFR (difference in adjusted eGFR change: +3.59 [2.96–4.11] mL/min/1.73 m2/y, p = 0.009), fasting glucose(−17 mg/dL; 95% CI = −22, −12), HbA1c (−0.62%; 95% CI = −0.87%, −0.37%), LDL-C (−39 mg/dL; 95% CI = −45, −33), triglycerides (−36 mg/dL, 95% CI = −46, −26), HDL-C (+10 mg/dL; 95% CI = +8, +11), and inflammatory markers
  • The observed benefits were associated with downregulation of hepatic NF-kB which is a proinflammatory transcription factor and a known curcumin target

My take: A larger multicenter study is needed to confirm these promising results. This study shows that dietary changes and lifestyle modification remain important tools in treating MASH (aka NASH).

Related editorial (open access!): S Zelber-Sagi, JM Schattenberg. Hepatology 2025; 81: 399-401. Is curcumin the new kid on the block for the treatment of MASH?

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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.

How to Successfully Appeal Health Insurance Denials

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Both of these articles are behind paywall. Thanks to Seth for these references.

Excerpt from first article:

“Health insurers process more than five billion payment claims annually, federal figures show. About 850 million are denied, according to calculations by appeals company Claimable, based on data from health-policy nonprofit KFF and the Centers for Medicare and Medicaid Services. Less than 1% of patients appeal.

Few people realize how worthwhile those labors can be: Up to three-quarters of claim appeals are granted, studies show…”

The author then details how one man overcame a denial to receive a life-saving liver transplantation and how a family helped their child receive immunoglobulin therapy for her neurologic condition. However, this only occurred after numerous appeals and after letters to the Georgia governor and Georgia attorney general.

Excerpts from the second article:

“Here are five things you can do to appeal a denied health-insurance claim.

1. Read up

Know what your plan covers. A good place to start is the summary of benefits and coverage. More detailed information should be available from your employer or insurer, which can provide a more in-depth document sometimes called the “evidence of coverage.” Check to make sure a denial met your insurer’s own rules. These policies are generally available online.

2. Take note

Log dates of calls to your insurer and whom you spoke to. Save paperwork including billing codes for denied services. And act quickly: Insurers have deadlines to file appeals.

3. Fight back

Call your insurer at the number on the back of your insurance card and ask why treatment wasn’t covered. You can ask how to file an appeal. If you have a denial or explanation of benefits letter, look for the section explaining appeals.

4. Get help

State assistance programs and nonprofits including the Patient Advocate Foundation and the Medicare Rights Center can help craft appeals. A startup called Claimable is trying to use technology to smooth the process. You can hire an advocate, looking through a directory or a third-party company, Solace Health. The nonprofit Dollar For helps with hospital bills. You can also ask your doctor’s office or hospital to appeal for you, and try to ensure they keep you in the loop on their communications.

5. Escalate

After you determine why your insurer denied a claim, you can write a letter explaining why the rejection wasn’t warranted. Your doctor can write a letter explaining why care is medically necessary. Pertinent medical studies can strengthen your case. Request the “designated record set” relevant to your case.

If your appeal is rejected, you can often appeal to a higher authority within the insurer. If that fails, you can generally appeal to a third party, often an independent review organization or a government-administered program. Your rejection letter or state insurance department should explain those steps. Practices vary state by state. You can also escalate your appeal to an administrative law judge.”

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What It Might Look Like When Trying To Get Past an Insurance Denial

Antibiotics and IBD Risk: A Systematic Review

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R Duan et al. Clin Gastroenterol Hepatol 2025; 23: 45-58. Open Access! Antibiotic Exposure and Risk of New-Onset Inflammatory Bowel Disease: A Systematic Review and Dose-Response Meta-Analysis

Twenty-eight studies involving 153,027 patients with IBD were included.

Key findings:

  • Antibiotic exposure was significantly associated with an increased risk of new-onset IBD for prescription-based studies (pooled OR, 1.41; 95% CI, 1.29–1.53) and for questionnaire-based studies (pooled OR, 1.35; 95% CI, 1.08–1.68). ‘
  • This association existed for both Crohn’s disease and ulcerative colitis, as well as in children and adults for prescription-based studies. 

Some of the limitations:

  1. There was statistical heterogeneity was high in the primary analysis, possibly because of inconsistencies in study design
  2. Most studies included a clear lag time, yet an inadequate lag time still creates the possibility of reverse causality.
  3. The authors could not disentangle the risk of antibiotics from the risk of infection in leading to the development of IBD.
Nonlinear dose-response relationship between antibiotic exposure and risk of new-onset IBD (solid black line and short dash black line represent estimated ORs and corresponding 95% CIs of nonlinear relationship)

My take: This is another study showing an association between antibiotic use and new-onset IBD. While this study does not prove causation, it is another reason for good antibiotic stewardship.

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Understanding New Risks for Clinicians Under Utah’s Health Law

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K Underhill, KM Nelson. NEJM 2025; 392: 523-525. Legal Threats to Clinicians and Patients

An excerpt:

In January 2023, Utah added a section to its Health Care Malpractice Act (see box). The change was part of Senate Bill 16, a larger package of laws targeting gender-affirming care. The new Malpractice Act language specifies that for “hormonal transgender treatment” and surgery on “sex characteristics,” patients treated when they are minors have the option to disaffirm — revoke — their consent before 25 years of age...

Although patients consent at the time of treatment, Utah’s new law enables them to withdraw their informed consent retroactively, even years later, and pursue legal claims based on being treated without consent...

Utah’s new law places a tremendous burden on clinicians…

It is unrealistic and unreasonable to expect clinicians to predict which patients may later reverse their consent to treatment. Clinicians who undertake these predictions will make mistakes in both directions — either failing to predict regrets (which are rare2) or, more likely, erroneously denying medically necessary care to minors who would benefit from it…

 Allowing minors to recant their consent undermines the efforts that many states have made to strengthen minors’ independent access to care for sexual health, mental health, and substance use. Laws that have a chilling effect on medical services can also interfere with the pipeline of clinicians who have the training and experience to deliver care, reducing access for all patients…

Utah’s law is more worrisome, however, as a potential harbinger of things to come…As legislators develop and test state laws interfering with gender-affirming care, the same strategies become available for other politically contested forms of health care.

My take: Allowing individuals to recant consent for treatment years later will undermine access to all types of health care.

Related article: DG Aaron, C Konnoth. NEJM 2025; 392: 526-528. This article explains the flawed “Cass Review” which was a a 388-page report commissioned by England’s National Health Service (NHS) concluded that “there is not a reliable evidence base upon which to make clinical decisions” regarding gender-affirming care (GAC).

“Our concern here is that the Review transgresses medical law, policy, and practice, which puts it at odds with all mainstream U.S. expert guidelines. The report deviates from pharmaceutical regulatory standards in the United Kingdom. And if it had been published in the United States, where it has been invoked frequently, it would have violated federal law because the authors failed to adhere to legal requirements protecting the integrity of the scientific process..3 The Review calls for evidentiary standards for GAC that are not applied elsewhere in pediatric medicine.“

Grand Palace in Bangkok

Managing Drug-Induced Acne in IBD: A Guide for Gastroenterologists

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MJ Temido et al. Am J Gastroenterol 2025;120:125–134. Drug-Induced Acne in Inflammatory Bowel Disease: A Practical Guide for the Gastroenterologist

“Corticosteroids and Janus kinase inhibitors (JAKi) are commonly used for the treatment of inflammatory bowel disease (IBD) and are known to aggravate a prior tendency to acne or trigger the development of new acneiform eruptions. Both randomized controlled trials and real-world studies have identified acne as one of the most common treatment-emergent adverse events in JAKi… This review examines the characteristics of drug-induced acne in IBD treatments, provides a practical guide for gastroenterologists to manage mild-to-moderate occurrences, and highlights when to seek specialist dermatology advice.”

My take: This is a helpful review of acne management in the setting of IBD.

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.

ACG 2025 Guidelines for Eosinophilic Esophagitis

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ES Dellon et al. The American Journal of Gastroenterology  2025;120(1):p 31-59. Open Access! ACG Clinical Guideline: Diagnosis and Management of Eosinophilic Esophagitis or bit.ly/acg-eoe-2025.

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The Future of Medicine: AI’s Role vs Human Judgment

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Pranav Rajpurkar and Eric J. Topol. NY Times Feb 2, 2025: The Robot Doctor Will See You Now

An excerpt:

“The medical community largely anticipated that combining the abilities of doctors and A.I. would be the best of both worlds, leading to more accurate diagnoses and more efficient care…That assumption might prove to be incorrect. A growing body of research suggests that A.I. is outperforming doctors, even when they use it as a tool…

Simply giving physicians A.I. tools and expecting automatic improvements doesn’t work. Physicians aren’t completely comfortable with A.I. and still doubt its utility, even if it could demonstrably improve patient care…

Medical training will need to adapt to help doctors understand not just how to use A.I., but when to rely on it and when to trust their own judgment…But the promise for patients is obvious: fewer bottlenecks, shorter waits and potentially better outcomes. For doctors, there’s potential for A.I. to alleviate the routine burdens so that health care might become more accurate, efficient and — paradoxically — more human.”

In a related Substack article (open access: Opinion | When A.I. Alone Outperforms the Human-A.I. Partnership), Dr. Topol and Dr. Rajpurkar list several studies showing that AI alone may be better than physicians with AI under some circumstances:

My take (borrowed from the authors): “The future of medicine won’t be shaped by a simple choice between human or artificial intelligence, but by our ability to understand their respective strengths and limitations, and to orchestrate their collaboration in ways that truly benefit patient care.”

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Early Management of Caustic Ingestions in Children

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Briefly noted: ES Gordon, E Barfiedl, BD Gold. J Pediatr Gastroenterol Nutr. 2025;1–12. Early management of acute caustic ingestion in pediatrics

Congratulations to my partner Dr. Gold and his coauthors.

Key points:

  • In symptomatic patients, EGD within 24‐hours is most optimal to evaluate the degree of injury and for prognostication
  • Further research is needed on the use of steroids, antibiotics, and acid‐suppression
  • Early placement of NGT under direct visualization during endoscopy may help prevent stricture formation and allow for enteral nutrition in cases of significant injury (Zargar grade 2b and above)

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Henoch-Schonlein Purpura Findings in the Duodenum

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L Torelli et al. J Pediatr Gastroenterol Nutr. 2025;80:242–244. Gastrointestinal involvement in Henoch–Schönlein purpura

A 10 yo underwent an EGD due to nausea, melena and abnormal CT (showing thickening in the  the duodenum and first jejunal loop. Two days later, she developed a cutaneous rash appeared on her legs, buttocks, and elbows.

Mucosal congestion with shallow ulcerations in the descending duodenum.

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