Time sensitive managements in hepato-gastroenterology

Table 1 Time-sensitive interventions focusing on drug-induced liver injury

Drug/class	Mechanism	Time sensitivity	Key intervention
Acetaminophen	Direct toxin (NAPQI)	< 8-12 hours for NAC efficacy	NAC, early levels, transplant if needed
Isoniazid	Hepatocellular (immune)	Days-weeks; need early stop	Monitor LFTs, stop the drug promptly
Halothane	Immune hepatitis	Re-exposure fatal	Avoid re-exposure, early stop
Amiodarone (IV)	Direct toxic	Hours-days	Discontinue if ALT/AST rise
Valproic acid	Mitochondrial dysfunction	Hours-days	Stop the drug, consider L-carnitine
Methotrexate (acute)	Overdose, accumulation	Hours (folinic acid critical)	Leucovorin rescue
DRESS-related drugs	Immune-mediated	Days; worsening if delayed stop	Stop all suspect drugs urgently
Herbal toxins	Idiosyncratic or direct	Hours-days	Stop supplement, list in history

NAPQI: N-acetyl-p-benzoquinone imine; NAC: N-acetylcysteine; LFT: Liver function test; IV: Intravenous; ALT: Alanine aminotransferase; AST: Aspartate aminotransferase.

Table 2 Postexposure prophylaxis in health care personnel

HCP vaccination status	HCP immune testing (HBsAb titre)	Source status (HBsAg) testing	Postexposure prophylaxis (PEP)		PEP protection testing (HBsAb titre)
			Vaccination	HBIG
Documented responder after CVCS	Not indicated	Not indicated	Not indicated	Not indicated	Not indicated
Documented non-responder after 2 CVCS	Anti-HBs < 10 IU/L	Negative	Not indicated	Not indicated	Not indicated
		Positive/unknown	Not indicated	Of 2 doses one month apart	Not indicated
Response not tested after CVCS	Anti-HBs ≥ 10 IU/L	Not indicated	Not indicated	Not indicated	Not indicated
	Anti-HBs < 10 IU/L	Negative	Re-vaccinate	Not indicated	Yes
		Positive/unknown	Start CVCS	One dose ASAP up to 7 days	Yes
Unvaccinated/incomplete VCS	Anti-HBs ≥ 10 IU/L (post infection recovery)	Not indicated	Not indicated	Not indicated	Not indicated
	Anti-HBs < 10 IU/L	Negative	Start CVCS	Not indicated	Yes
		Positive/unknown	Start CVCS	One dose ASAP up to 7 days	Yes

HCP: Health care personnel; HBsAb: Hepatitis B surface antibody; HBsAg: Hepatitis B surface antigen; PEP: Post-exposure prophylaxis; HBIG: Hepatitis B immune globulin; CVCS: Complete vaccination course series; VCS: Vaccination course series; ASAP: As soon as possible.

Table 3 Admission Model for Intensification of Therapy in Acute Severe Colitis score calculation at admission and expected rates of response to intravenous steroids[97]

Item	Score
CRP ≥ 100 mg/L	1
Albumin ≤ 25 gm/L	1
UCEIS ≥ 4	1
UCEIS ≥ 7	2
ADMIT-ASC score	Rate of steroid response
0	100%
1	69.6%
2	40.7%
3	17.5%
4	0%

CRP: C-reactive protein; UCEIS: Ulcerative Colitis Endoscopic Index of Severity; ADMIT-ASC: Admission Model for Intensification of Therapy in Acute Severe Colitis. Citation: Gisbert JP, Chaparro M. Common Mistakes in Managing Patients with Inflammatory Bowel Disease. J Clin Med 2024; 13: 4795. Copyright© The authors 2024. Published by MDPI, Basel, Switzerland (Supplementary material).

Table 4 Summary of the time-sensitive decisions in management of Clostridium difficile infection

Patient phenotype (stage of illness)	Recommended action	Time frame
Symptomatic (suspected)	Multi-step diagnostics + start empiric therapy (fidaxomicin or vancomycin)	Within 24 hours
Severe/fulminant	High-dose oral vancomycin + IV metronidazole; consider rectal vancomycin	Immediately
First recurrence	Switch to fidaxomicin	As early as possible after recurrence
≥ 2 recurrences	Add fecal microbiota transplantation promptly	As early as possible
Fulminant refractory to medical therapy	Surgical consultation (or ileostomy lavage)	Within hours/days of deterioration

Table 5 Zargar classification of corrosive esophageal injury[121]

Zargar classification	Findings
Grade 0	Normal finding on endoscopic examination
Grade 1	Edema and hyperemia of the mucosa
Grade 2a	Friability, blisters, exudates, hemorrhages, whitish membrane, erosions, and superficial ulceration
Grade 2b	Grade 2a + deep discrete or circumferential ulceration
Grade 3a	Small scattered areas of multiple ulceration and areas of necrosis with brown-black or grayish discoloration
Grade 3b	Extensive necrosis

Citation: Zargar SA, Kochhar R, Mehta S, Mehta SK. The role of fiberoptic endoscopy in the management of corrosive ingestion and modified endoscopic classification of burns. Gastrointest Endosc 1991; 37: 165-169. Copyright© American Society for Gastrointestinal Endoscopy 1991. Published by Mosby, Inc. All rights reserved (Supplementary material).

Table 6 Risk factors for colorectal cancer and the recommended timing of screening

Clinical situation	Ref.	Recommended age/time for screening colonoscopy	Recommended age/time for screening gastroscopy
Lynch syndrome	Ladigan-Badura et al[128], 2021	Every 1-2 years beginning between ages 20 years and 25 years or 2-5 years before earliest CRC diagnosis in the family, whichever is earlier	Considered especially for those with family history of gastric cancer and those of Asian ancestry; every 3-5 years beginning between the ages 30 years and 35 years
FAP	Weiss et al[129], 2021	Yearly starting at age 10 and continuing until colectomy; post-colectomy rectal or ileal pouch colonoscopy every 1-2 years; for attenuated FAP, yearly screenings should begin by age 20	Upper endoscopy to examine the stomach and duodenum at 20 years to 25 years; screening may start earlier if a patient undergoes colectomy before this age; the endoscopy should adequately visualize the ampulla of Vater (use of the side viewing endoscope may be advised)
Peutz-Jeghers syndrome	Weiss et al[129], 2021	Once the diagnosis is confirmed, regular surveillance and imaging are essential due to the increased malignancy risk; upper gastrointestinal endoscopy, video capsule endoscopy, and colonoscopy are recommended between ages 8 and 10 to screen for gastric, duodenal, and small bowel polyps; if polyps are detected on baseline screening, endoscopic evaluation should be repeated every 2 years to 3 years; if polyps are absent, screening should resume every 2 years to 3 years beginning at age 18
MUTYH-associated polyposis	Weiss et al[129], 2021	Colonoscopy with polypectomy every one to two years beginning at age 25-30 years; prophylactic colectomy when the polyps became unmanageable	Consider upper endoscopy (including side viewing duodenoscopy) exam at 30-35 years examination, which should evaluate the ampulla of Vater; repeat every three months to four years based on initial findings (number, size, and type of polyps found)
Juvenile polyposis syndrome	Shaheen et al[126], 2022	About 1-3 year interval range, start with symptoms or latest at 18-20 years
Hyperplastic polyposis		Every 1-2 years, prophylactic colectomy is performed when the polyps became unmanageable
Inflammatory bowel disease		See later
Post-endoscopic polypectomy		Depend on the size, morphology and histology of the polyp (Figure 2)
Post-surgical resection of CRC		In case of operated obstructive CRC where preoperative colonoscopy was not done, a colonoscopy should be carried out within 3-6 months after surgery; operated cases with pre-operative colonoscopy done should have colonoscopy at 1-year and 3-years from surgery, and once examination is unremarkable, revert to 5-year interval; if polyps are detected during colonoscopy the polyp surveillance intervals protocol should be followed

CRC: Colorectal cancer; FAP: Familial adenomatous polyposis; MUTYH: MutY DNA glycosylase.

Table 7 Surveillance for inflammatory bowel disease -related colonic dysplasia

Visible dysplastic lesions
Lesion	Treatment	Colonoscopy surveillance intervals
Small < 2 cm + resectable + no histologic features of invasive CRC	Endoscopic resection + continuous surveillance	Every 3-6 months in HGD or incomplete resection; 12 months: More than 1 cm and LGD; 24 months if < 1 cm, pedunculated, LGD
Large ≥ 2 cm, complex lesions, incomplete resection, after several attempts, local recurrence	Refer to a highly experienced center for resection vs surgery	Every 3-6 months if resected
Non-visible dysplastic lesions (detected by non-targeted biopsy) or incompletely delineated lesions on target biopsy should be examined by SDC
Persistent HGD or multifocal invisible dysplasia	Surgery
Persistent unifocal low-grade invisible dysplasia	Intensive surveillance with SDC	Every 3-6 months in HGD or multifocal dysplasia; 6-12 months: If LGD continues, surveillance till 2 consecutive negative high-quality SDC colonoscopies
No dysplasia at index colonoscopy; timing for the next colonoscopy depends on many factors for CRC risk
1-year	2-3 years	5-year
Moderate or severe inflammation at index colonoscopy; family Hx of CRC in FDR < 50 years; PSC; dense pseudo-polyposis; history of invisible dysplasia < 5 years	Mild inflammation at index colonoscopy; strong family Hx of CRC but no FDR < 50 years; features of prior severe colitis (moderate pseudo-polyposis + extensive scarring); history of invisible dysplasia > 5 years	Continuous disease remission since the last colonoscopy with mucosal healing on the current examination, plus either: ≥ 2 consecutive exams without dysplasia; minimal historical colitis extent (ulcerative proctitis or < 1/3 in Crohn’s disease)

CRC: Colorectal cancer; HGD: High-grade dysplasia; LGD: Low-grade dysplasia; SDC: Sebaceous duct carcinoma; FDR: First-degree relative; PSC: Primary sclerosing cholangitis.