Two guys talking **it - A Gastroenterology and Hepatology podcast

We're back for Season 2, and Jon and James kick things off with one of their favourite topics: Incretin mimetics. The gut is the biggest endocrine organ in the body, and the data in steatotic liver disease is now as good as anything we have in Hepatology for steatotic liver disease.James and Jon cover the basic pharmacology, how to start and titrate these drugs in practice, what to tell patients about stopping them, the muscle loss question, endoscopy and anaesthesia, and a brief look at where the evidence is going across cardiovascular disease, kidney disease, sleep apnoea, IBD, and cancer. There is a lot going on with these drugs and this episode is the primer.As always comments, questions, feedback and suggestions please send to: X: @2guystalkingit Email: 2guystalkingit@gmail.comChapters00:00 Intro: Season 2 is here 03:00 What are incretins? The gut as endocrine organ 06:30 Origin story: Gila Monster and the GLP-1 breakthrough 08:30 The drugs: semaglutide, tirzepatide, and what's coming 10:00 How they actually work: satiety, the brain, and fat oxidation 12:00 Who to start: patient selection and caution groups 13:30 Lean MASH and Southeast Asian BMI thresholds 16:00 Exercise, muscle loss, and the resistance training argument 18:30 Side effects: nausea, constipation, lipase, mood 21:00 Endoscopy and anaesthesia: what to do 24:00 Titrating in practice: James's approach 28:00 Stopping the drug: weight regain and the SURMOUNT data 33:00 Personalising treatment: who can stop, who shouldn't 35:00 Eating disorders, body image, and screening 37:00 MASH data: ESSENCE and Synergy-NASH trials 39:30 Oral formulations: what's available and caveats 40:30 Where bariatric surgery still fits 42:00 Broader indications: IBD, CVD, CKD, cancer 45:00 Global obesity trends and the public health message 47:00 Wrap-upPapers discussedESSENCE trialSynergy-NASH trialSURMOUNT-MAINTAINTirzepatide and fat oxidation, Cell Metabolism 2025GLP-1 receptor agonists and 13 obesity-associated cancersSELECT trialFLOW trialSURMOUNT-OSASTEP 9: Semaglutide in obesity and knee osteoarthritisPsoriatic Arthritis paper

Today we had the privilege of talking to a true superstar in the world of Hepatology.Elliot B. Tapper MD is an Associate Professor in the Division of Gastroenterology and Hepatology at the University of Michigan. He is Academic Chief of Hepatology. His primary goal is to empower patients to enjoy a high quality of life. He is an expert in the management of chronic liver disease, performance of clinical trials, and big data for the study of liver disease. He has developed strategies that reduce symptoms and improve quality of life and invented tools that have helped keep patients with cirrhosis at home and away from the hospital. He is the Editor-in-Chief of Hepatology Communications.In this episode, A/Prof Tapper discusses his journey in hepatology, the impact of social media on medical education, and his innovative research on muscle cramps and pickle juice. He debunks common myths surrounding methotrexate and liver disease, explores the complexities of ammonia levels in hepatic encephalopathy, and shares insights on frailty in liver disease management. The conversation also touches on the evolving perspectives on antibiotic prophylaxis in cirrhosis and the critical importance of diagnostic paracentesis. Elliot emphasizes the positive aspects of hepatology and the exciting developments in the field.As always comments, questions and feedback please send to: X: @2guystalkingitEmail: 2guystalkingit@gmail.comChapters05:08 Introduction to Elliot and His Work08:14 The Power of Social Media in Medical Education11:10 The Fascination with Pickle Juice and Muscle Cramps14:00 Innovative Research During COVID-1917:01 Exploring Non-Pharmaceutical Interventions20:04 Debunking Myths Around Methotrexate and Liver Disease23:10 Addressing Misconceptions About Medications25:56 The Impact of AI on Medical Literature28:56 The Ammonia Debate in Clinical Practice30:17 Understanding Ammonia as a Clinical Biomarker37:28 Assessing Frailty in Liver Disease Patients44:20 Reevaluating SBP Prophylaxis in Cirrhosis49:03 The Importance of Diagnostic Paracentesis52:34 The Positive Side of HepatologyKeywordsElliot Tapper, hepatology, liver disease, medical education, social media, muscle cramps, methotrexate, ammonia levels, frailty, antibiotic prophylaxis, diagnostic paracentesis

Today we welcome two world-leading dietitians to talk all things diet in IBD and IBS....A/Prof Emma Halmos is a senior research dietitian at Monash University and the Alfred Hospital. Her scientific achievements have had a major impact in clinical practice nationally and internationally. The most notable was the pivotal feeding study that demonstrated the low FODMAP diet was efficacious in patients with IBS. A/Prof Halmos has been elected onto the D-ECCO (Dietitians of European Crohn’s and Colitis Organisation) committee and is a leading coordinator for the first ECCO guidelines on nutrition in IBD. Her current role at Monash University is leading research on novel dietary therapy to treat IBD and IBS.Dr CK Yao is a senior research dietitian at Monash University and the Alfred Hospital, and recent NHMRC emerging leader. In 2017, CK completed her PhD investigating dietary manipulation of gut microbial function and the application of gaseous biomarkers in patients with functional and inflammatory bowel disease. Dr Yao currently leads a research programme looking at optimising dietary strategies for patients with ulcerative colitis and those with an ileoanal pouch.We discuss the critical role of diet in managing inflammatory bowel disease (IBD), particularly Crohn's disease and ulcerative colitis. We explore various dietary patterns, the impact of emulsifiers and ultra-processed foods, and the importance of personalized dietary advice. We talk about the significance of dietitians in guiding patients towards healthier choices. This conversation delves into the complexities of dietary recommendations for various gastrointestinal conditions, particularly focusing on the Mediterranean diet, Crohn's disease, and IBS. We discuss cultural influences on diet, the importance of personalized nutrition, and the emerging trends in dietary therapy. Finally we touch on the new ECCO Diet in IBD guideline that is set to be published soon.As always comments, questions and feedback please send to: X: @2guystalkingitEmail: 2guystalkingit@gmail.comChapters00:00 Introduction with J & J4:20 On to our guests... Diet and IBD05:50 Dietary Patterns for Disease Prevention08:53 Therapeutic Diets and Active IBD11:58 Controversies in Dietary Recommendations15:02 The Impact of Emulsifiers and Ultra-Processed Foods18:07 Practical Dietary Advice for Patients in IBD21:02 Cultural Considerations in Dietary Recommendations23:57 Food as Medicine: A Discussion27:03 Exploring Diverse Dietary Patterns30:13 Conclusion and Future Directions32:26 Cultural Influences on Diet and Health34:40 Dietary Recommendations for active Crohn's Disease37:22 Understanding Pouch Patients38:11 Initial Assessment for IBS Patients44:25 Screening for ARFID48:03 Emerging Dietary Trends in IBS51:40 New Guidelines in IBD NutritionPapers discussedFitzpatrick JA, Gibson PR, Taylor KM, Anderson EJ, Friedman AB, Ardalan ZS, Smith RL, Halmos EP. Clinical Trial: The Effects of Emulsifiers in the Food Supply on Disease Activity in Crohn's Disease: An Exploratory Double-Blinded Randomised Feeding Trial. Aliment Pharmacol Ther. 2025 Apr;61(8):1276-1289. https://pubmed.ncbi.nlm.nih.gov/39967287/Fitzpatrick JA, Gibson PR, Taylor KM, Halmos EP. Development of Novel High and Low Emulsifier Diets Based upon Emulsifier Distribution in the Australian Food Supply for Intervention Studies in Crohn's Disease. Nutrients. 2024 Jun 18;16(12):1922. . https://pubmed.ncbi.nlm.nih.gov/38931276/Halmos EP, Gibson PR. Controversies and reality of the FODMAP diet for patients with irritable bowel syndrome. J Gastroenterol Hepatol. 2019 Jul;34(7):1134-1142. https://pubmed.ncbi.nlm.nih.gov/30945376/A FODMAP Gentle approach: https://www.monashfodmap.com/blog/gentle-fodmap-diet/The SCOFF Questionnaire: https://ceed.org.au/wp-content/uploads/2024/05/SCOFF.pdf

This is a really special episode with an incredible doctor (Jon says "the best clinician I have ever met"). Today we welcome Dr Simon Gabe, an internationally renowned expert in intestinal rehabilitation. Dr Simon Gabe is a consultant in gastroenterology & intestinal rehabilitation at St Mark’s Hospital and chair of the NHS National Reference Centre for Severe Intestinal Failure at St Mark’s. This is also an Integrated Care centre for intestinal failure and a recognised ESPEN Training Centre. He has a wide clinical experience in dealing with complex nutritional problems, inflammatory bowel disease, fistula management, intestinal failure requiring enteral or parenteral support, home parenteral nutrition and consideration of intestinal transplantation. Dr Gabe is a past President of BAPEN. He co-founded the National Adult Small Intestinal Transplant (NASIT) Forum in the UK and has been an active member of a Clinical Reference Group within NHS England responsible for the development of a clinical network in England for all patients with Intestinal Failure (HIFNET). He currently co-chairs the HPN Clinical Advice and Management Group for NHS England.As always comments, questions and feedback please send to: X: @2guystalkingit Email: 2guystalkingit@gmail.comChapters04:15 Introduction to Simon Gabe 06:59 Understanding Intestinal Rehabilitation 09:56 Defining Intestinal Failure 13:29 Trends in Intestinal Failure Causes 16:23 Bowel Length and Nutritional Support 20:26 Managing Short Bowel Syndrome 26:06 Barriers to Recognizing Intestinal Failure 30:37 Patient Evaluation Process for Intestinal Failure 33:07 Empowering Patients in Line Management 36:21 Managing Line Sepsis: Best Practices 43:17 Understanding Ehlers-Danlos Syndrome (EDS) and Nutrition 50:14 Nutritional Support in Cancer Patients 54:18 Enteral Support in Dementia Patients 57:15 Addressing Intestinal Ischemia: A Call to Action KeywordsIntestinal rehabilitation, intestinal failure, nutrition, gastroenterology, patient care, bowel length, short bowel syndrome, nutritional support, clinical practice, healthcare, line management, line sepsis, Ehlers-Danlos Syndrome, nutritional support, cancer patients, dementia, intestinal ischemia, patient empowerment, multidisciplinary team, intravenous nutrition

We very excited about the episode today!We are joined by A/Professor Jason Tye-Din - a leading expert in coeliac disease and immune-mediated gut disorders. He is Coeliac labratory head at the Walter and Eliza Hall Institute of Medical Research, a Mathison Centenary Fellow at the University of Melbourne, and consultant Gastroenterologist at the Royal Melbourne Hospital. His work focuses on the immunology of coeliac disease, novel diagnostic approaches, and developing non-dietary treatments. He is also one of the smartest (and nicest) clinicians that we have had the privilege of working with. Joining Jason on the podcast today is Dr Cynthia Kanagasundaram. Cynthia is a UK trained Consultant Gastroenterologist with a vast experience in all things gastroenterology. She prides herself on innovation and has developed a novel GUT HUT service which slashed waiting times and improved patient care. She is embarking on a new stage of her career exploring novel diagnostics, techniques and treatments in Coeliac disease in the Tye-Din lab at the WEHI with A/Prof Jason Tye-Din as her supervisor.Today we delve into the complexities of coeliac disease. We cover the diagnosis, dietary management, refractory celiac disease, models of care and future of coeliac.The International Celiac Disease Symposium (ICDS 2026) will be held in Melbourne Australia 17-20 November 2026. Details at https://www.icds2026.orgChapters00:20 Introduction with Jon and James04:42 Introduction to A/Prof Tye-Din and Dr Kanagasundaram06:42 Understanding Coeliac Disease: Diagnosis and Patient Education09:17 Dietary Considerations: Foods to Avoid and Oats Discussion12:44 Biopsy Guidelines and Diagnostic Approaches16:44 Revisiting Biopsy Techniques and Clinical Observations19:40 Mucosal Healing and Follow-Up Practices22:35 Refractory Coeliac Disease: Definitions and Management26:48 Treatment Strategies for Refractory Coeliac Disease31:14 Understanding Treatment Targets in Coeliac Disease32:16 Maintenance Treatment for Refractory Coeliac Disease33:13 Exploring Alternative Treatment Options34:12 Balancing Treatment Risks and Benefits34:59 Advancements in Histology and Scoring Systems37:05 Future Directions in Coeliac Disease Research39:01 Innovations in Diagnosis and Screening41:01 The Role of Gluten Challenges in Diagnosis43:14 Understanding the Causes of Coeliac Disease45:14 Patient Management and Follow-Up Care48:12 Vaccination and Hyposplenism56:13 Opportunities for Research and CollaborationLinks to papers mentionedIron deficiency.(Link)2020 ESPGHAN Guidelines for diagnosing Coeliac Disease Clinical and Immunologic Features of Ultra-Short Celiac Disease. (Link)A prospective, double-blind, placebo-controlled trial to establish a safe gluten threshold for patients with celiac disease.(Link)Diagnostic outcomes after gluten challenge in adult patients with unconfirmed coeliac disease already on a gluten-free diet: A 20-year retrospective cohort study.(Link)AGA Clinical Practice Update on Management of Refractory Celiac Disease: Expert Review. (Link)Open-Capsule Budesonide for Refractory Celiac Disease. (Link)Budesonide Induces Favourable Histologic and Symptomatic Recovery in Patients with Non-responsive and Refractory Coeliac Disease When Given in an Open Capsule Format. (Link)Stool Gluten Peptide Detection Is Superior to Urinary Analysis, Coeliac Serology, Dietary Adherence Scores and Symptoms in the Detection of Intermittent Gluten Exposure in Coeliac Disease: A Randomised, Placebo-Controlled, Low-Dose Gluten Challenge Study. https://doi.org/10.3390/nu16020279Impaired IgM Memory B Cell Function Is Common in Coeliac Disease but Conjugate Pneumococcal Vaccination Induces Robust Protective Immunity. (Link)

Every podcast is incomplete without a 'best of' episode from the previous year. In this episode Jon and James talk about their big learnings / seminal papers / themes of 2024 in Gastroenterology and Hepatology. We wish we could have included more! As always, please leave questions/comments either below or on our X (@2guystalkingit).

Hello world.. Welcome to Two guys talking **it - a podcast designed for gastroenterologists and hepatologists or anyone interested in the field. Each week, join Jon and James as we bring you expert discussions, the latest research, and practical clinical insights amongst a lot of talking **it.. In this episode we briefly introduce the podcast. Bear with us as we try to work this thing out! Please leave any comments or requests for future episodes, or catch us on twitter (@Jonathansegal85 or @JamesHaridy)