Board Pearls

By Board Pearls

The most complete gastroenterology board-review podcast on the web, and it is entirely free. This is the GI series from Board Pearls: board review built around clinical reasoning, not recall. Every ep... more

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How many episodes does Board Pearls have?

The podcast currently has 153 episodes available.

Board Pearls episodes:

July 16, 2026Chapter 36, Ep 5 of 5: Hereditary Pancreatic Cancer and Coordination
Episode five closes the chapter with hereditary pancreatic cancer and the family-systems coordination that binds every syndrome together. The gating principle is absolute lifetime risk, not relative risk: surveillance begins above roughly five percent, so STK11, CDKN2A, PRSS1, and familial kindreds qualify on genotype alone while BRCA1, BRCA2, ATM, PALB2, and Lynch enter only with a family-history driver. The treatment side ties platinum and PARP inhibitors back to synthetic lethality in homologous-recombination-deficient tumors. The coordination side names the real failure mode, the carrier whose colonoscopy stays on schedule while gynecologic or urologic surveillance lapses, and the board traps around cascade testing, the GINA insurance gap, and the non-actionable variant of uncertain significance.

Topics covered
Germline genes behind pancreatic cancer
The absolute-risk surveillance threshold
Which carriers qualify on gene alone
Surveillance starting ages and modality
PRSS1 hereditary pancreatitis
Synthetic lethality, platinum, and PARP inhibitors
Multi-organ coordination and cascade testing
Risk-reducing surgery and reproductive counseling
GINA limits and variants of uncertain significance

Key decisions
Gate pancreatic surveillance on absolute lifetime risk above approximately five percent, above which cancer detection outweighs the false positives, procedural complications, and cyst-driven anxiety below it.
Enroll STK11, CDKN2A, PRSS1, and familial pancreatic cancer kindreds on genotype or pedigree alone, but enroll BRCA1, BRCA2, ATM, PALB2, and Lynch carriers only with a first-degree or second-degree relative with pancreatic cancer.
Start surveillance at thirty to thirty-five for STK11, forty for CDKN2A and PRSS1, and fifty for BRCA, ATM, PALB2, and Lynch, or ten years before the earliest family pancreatic cancer, whichever is younger.
Alternate annual EUS and pancreatic-protocol MRI with MRCP because they are complementary, EUS for solid lesions and same-session sampling, MRI for cysts and ductal anatomy without procedural risk.
Offer maintenance olaparib after at least sixteen weeks of platinum-based chemotherapy without progression in germline BRCA metastatic pancreatic cancer, because it roughly doubled progression-free survival and germline panel testing is now standard at diagnosis.
Do not act on a variant of uncertain significance: it does not justify cascade testing or gene-specific surveillance, and the program stays anchored to personal and family history.
Counsel carriers that GINA covers health insurance and employment but not life, disability, or long-term care insurance, and advise obtaining those policies before testing.

Study the full chapter on Board Pearls, with practice questions, tables and primary-guideline references: Hereditary GI Cancer Syndromes
Read this episode: boardpearls.com/gi/episodes/hereditary-gi-cancer-syndromes-ep5
Questions or feedback: [email protected].
(00:00) - Germline genes behind pancreatic cancer
(00:39) - Two mechanistic gene families
(01:42) - The absolute-risk surveillance threshold
(03:50) - Starting ages and surveillance modality
(04:36) - Alternating EUS and MRI
(05:51) - PRSS1 hereditary pancreatitis
(07:03) - Synthetic lethality and PARP inhibitors
(09:56) - Multi-organ coordination and cascade testing
(12:53) - GINA limits and the VUS trap
...more
17min
July 16, 2026Chapter 36, Ep 4 of 5: Hamartomatous Polyposis and Diffuse Gastric Cancer
Episode four moves from adenoma to hamartoma, where the dominant risk shifts away from colorectal cancer. STK11 drives Peutz-Jeghers, and the resection threshold is calibrated to intussusception rather than cancer, so any small bowel polyp over one centimeter comes out. PTEN drives Cowden, where the cancer burden tracks baseline PI3K signaling into breast and thyroid and the GI role is recognition through mixed-histology polyposis. CDH1 flips the algorithm hardest: multifocal submucosal signet-ring disease beneath intact mucosa makes endoscopy unreliable, so prophylactic total gastrectomy between twenty and thirty is the standard of care. The thread is constant, the gene dictates the histology, the histology dictates the natural history, and the natural history dictates whether the answer is surveillance, polyp-by-polyp resection, or removal of the organ.

Topics covered
Peutz-Jeghers, STK11, and buccal pigmentation
Arborizing hamartomas and intussusception risk
Small bowel resection thresholds
Peutz-Jeghers multi-organ cancer surveillance
PTEN hamartoma spectrum and Cowden
Hereditary diffuse gastric cancer and CDH1
Prophylactic total gastrectomy
The Cambridge surveillance protocol
GAPPS as the HDGC differential

Key decisions
Resect any Peutz-Jeghers small bowel polyp greater than one centimeter, any symptomatic polyp regardless of size, and any polyp showing rapid growth, because growth velocity predicts intussusception better than absolute size.
Start Peutz-Jeghers surveillance young with baseline EGD and colonoscopy at age eight to ten plus small bowel capsule or MR enterography, avoiding CT enterography because of cumulative radiation across decades.
Enroll STK11 carriers in pancreatic surveillance on the gene alone, unlike BRCA, ATM, PALB2, and Lynch, because STK11 lifetime pancreatic risk clears the absolute-risk threshold without a family-history modifier.
Read Cowden as a breast and thyroid syndrome, with annual thyroid ultrasound from diagnosis, breast MRI and mammography from the early thirties, and no prophylactic thyroidectomy because the cancers are follicular and papillary rather than medullary.
Recommend prophylactic total gastrectomy with Roux-en-Y reconstruction between ages twenty and thirty for confirmed CDH1 carriers, because random biopsy misses multifocal submucosal signet-ring foci that sit beneath grossly intact mucosa.
Offer the Cambridge protocol of annual EGD with thirty to fifty random biopsies only as a fallback for CDH1 carriers awaiting or declining surgery, counseling explicitly that surveillance failure is documented despite rigorous adherence.
Add annual breast MRI plus mammography from age thirty for female CDH1 carriers, because lobular breast cancer risk reaches forty to fifty-five percent and mammography detects it less reliably.

Study the full chapter on Board Pearls, with practice questions, tables and primary-guideline references: Hereditary GI Cancer Syndromes
Read this episode: boardpearls.com/gi/episodes/hereditary-gi-cancer-syndromes-ep4
Questions or feedback: [email protected].
(00:00) - Peutz-Jeghers, STK11, and buccal pigmentation
(02:05) - Arborizing hamartomas and intussusception
(03:03) - The small bowel resection threshold
(04:36) - Multi-organ cancer surveillance
(05:33) - The recognition cancers to memorize
(06:57) - The PTEN spectrum and Cowden
(10:56) - CDH1 and hereditary diffuse gastric cancer
(13:00) - The Cambridge surveillance fallback
(14:56) - GAPPS as the differential
...more
18min
July 16, 2026Chapter 36, Ep 3 of 5: Adenomatous Polyposis: FAP and MUTYH
Episode three works the adenomatous polyposis syndromes by their governing logic: if you know the gene, you know the polyp count, the polyp type, and the surgery. APC drives classic FAP toward near-certain colorectal cancer by forty, the same gene at its ends produces the softer attenuated phenotype, and biallelic MUTYH mimics attenuated FAP through an autosomal recessive pattern of affected siblings and unaffected parents. The surgical pivot is not whether to take the colon but whether to take the rectum, which decides itself on polyp burden. After the colon is gone the duodenum becomes the surveillance organ, with Spigelman staging turning ampullary adenomas into an EGD interval and a pancreaticoduodenectomy conversation.

Topics covered
Reasoning from gene to polyp count to surgery
Classic FAP and APC on Wnt signaling
Attenuated FAP and the Ashkenazi variant
MUTYH-associated polyposis and recessive inheritance
FAP extracolonic stigmata and desmoids
Prophylactic colectomy and the rectal decision
Spigelman-staged duodenal surveillance
Chemoprevention as adjunct not substitute

Key decisions
Start annual colonoscopy at puberty, age ten to twelve, in classic FAP, and delay attenuated FAP and MUTYH-associated polyposis to age twenty to twenty-five because the polyps and cancer arise later.
Move to prophylactic colectomy for polyps larger than ten millimeters, high-grade dysplasia, rising polyp number, burden too high to clear endoscopically, or symptoms.
Let the rectum decide the operation: total proctocolectomy with ileal pouch-anal anastomosis when the rectum carries burden, total colectomy with ileorectal anastomosis with annual rectal surveillance when it can be cleared.
Test for biallelic MUTYH in a patient with multiple adenomas who is APC-negative, especially when a sibling is affected and the parents are not, because the pattern is autosomal recessive.
Stage the duodenum by Spigelman and set the interval to the stage: EGD every four years at stage zero down to every year at stage three, with side-viewing ampulla inspection each time, because stage four carries a fourteen to thirty-six percent cancer risk and triggers surgical evaluation.
Treat sulindac and celecoxib as adjuncts only, since they reduce polyp number but do not prevent colorectal cancer or remove the need for surgery.

Study the full chapter on Board Pearls, with practice questions, tables and primary-guideline references: Hereditary GI Cancer Syndromes
Read this episode: boardpearls.com/gi/episodes/hereditary-gi-cancer-syndromes-ep3
Questions or feedback: [email protected].
(00:00) - Gene sets count, histology, and surgery
(00:53) - Classic FAP and APC on Wnt signaling
(01:39) - Attenuated FAP and the Ashkenazi variant
(02:19) - MUTYH-associated polyposis and recessive inheritance
(03:30) - Extracolonic stigmata and desmoids
(04:52) - Colectomy and the rectal decision
(06:00) - Spigelman-staged duodenal surveillance
(07:20) - Chemoprevention as adjunct not substitute
...more
10min
July 16, 2026Chapter 36, Ep 2 of 5: Lynch Syndrome and Gene-Specific Risk
Episode two takes Lynch syndrome, the syndrome the diagnostic framework most often surfaces, and anchors everything to one idea: lifetime cancer risk varies sharply by gene, and that gene-specific risk sets each surveillance interval to the dwell time of preinvasive disease in that organ. MLH1 and MSH2 carriers drive high colorectal and endometrial risk, while MSH6 flips uterine cancer above colorectal and MSH2 concentrates the upper urothelial risk. The reasoning extends to why the colonoscopy interval is short, why the cancer operation is extended, why endometrial surveillance is a bridge to hysterectomy, and why aspirin and pembrolizumab both trace back to the mutational burden the syndrome generates.

Topics covered
Mismatch-repair genetics and the MSI phenotype
Classic Lynch tumor histology and late-presenting carriers
Amsterdam and Bethesda criteria
Gene-specific lifetime cancer risk
Colorectal surveillance and extended colectomy
Endometrial surveillance as a bridge to hysterectomy
Urothelial, gastric, and pancreatic programs
Aspirin chemoprevention and checkpoint inhibition
Lynch variants and Syndrome X

Key decisions
Run colonoscopy every one to two years starting age twenty to twenty-five, or five years before the youngest affected relative, because Lynch adenomas progress faster than sporadic ones and a three-year interval is too long.
When a Lynch carrier develops colorectal cancer, particularly an MLH1 or MSH2 carrier, perform extended colectomy with ileorectal anastomosis rather than segmental resection, because metachronous risk in the residual colon is high, then surveil the rectum annually.
Treat MSH6 as the exception where uterine cancer outranks colorectal, discuss risk-reducing hysterectomy earlier, and offer total hysterectomy with bilateral salpingo-oophorectomy after childbearing as a bridge target rather than relying on surveillance permanently.
Gate pancreatic surveillance on family history, enrolling only carriers with a first-degree or second-degree relative with pancreatic cancer in annual EUS or MRI at age fifty, because absolute Lynch pancreatic risk near six percent sits below the surveillance threshold.
Offer daily aspirin for chemoprevention across a tolerable dose range, counseling that the colorectal benefit emerges only beyond five years and the per-protocol effect exceeds the intention-to-treat estimate.
Give pembrolizumab first-line for advanced MSI-high or mismatch-repair-deficient Lynch cancers before chemotherapy, because the high mutational burden generates the neoantigens checkpoint inhibition needs.

Study the full chapter on Board Pearls, with practice questions, tables and primary-guideline references: Hereditary GI Cancer Syndromes
Read this episode: boardpearls.com/gi/episodes/hereditary-gi-cancer-syndromes-ep2
Questions or feedback: [email protected].
(00:00) - Mismatch-repair genetics and the MSI phenotype
(01:20) - Classic histology and late-presenting carriers
(01:54) - Amsterdam and Bethesda criteria
(02:28) - Gene-specific lifetime cancer risk
(03:58) - Colorectal surveillance and extended colectomy
(04:43) - Endometrial surveillance as a bridge to surgery
(05:40) - Urothelial, gastric, and pancreatic programs
(08:06) - Aspirin and checkpoint inhibition
(09:38) - The Lynch variants and Syndrome X
...more
14min
July 16, 2026Chapter 36, Ep 1 of 5: Tumor Screening and Reflex Testing
Episode one of the Hereditary GI Cancer Syndromes chapter builds the diagnostic framework the rest of the series depends on. The organizing idea: universal tumor testing catches the carriers that pedigree gatekeeping misses, because family history alone overlooks thirty to fifty percent of them. The four-protein immunohistochemistry pattern then decides the next move, with combined MLH1 and PMS2 loss running a sporadic-cancer rule-out before germline sequencing and everything else reflexing straight to the blood test. The through-line is that protein-loss pattern drives testing, and once a proband is confirmed, cascade testing of relatives becomes the highest-yield step.

Topics covered
Why tumor testing replaces pedigree gatekeeping
Universal four-protein MMR immunohistochemistry
Universal endometrial IHC and the sentinel cancer
The reflex pathway and IHC patterns
MLH1 and PMS2 loss with the BRAF and methylation gate
EPCAM and the MSH2 and MSH6 pattern
Multi-gene panels and phenotype overlap
Cascade testing and multidisciplinary referral

Key decisions
Run universal four-protein mismatch-repair immunohistochemistry, MLH1, MSH2, MSH6, and PMS2, on every newly diagnosed colorectal and endometrial cancer, because pedigree-based screening misses thirty to fifty percent of carriers.
On combined MLH1 and PMS2 loss, test the tumor for BRAF V600E first and then MLH1 promoter methylation; only when both are absent does the patient reflex to germline sequencing, because roughly seventy percent of that pattern is sporadic.
Isolated loss of MSH2, MSH6, or PMS2 has no sporadic counterpart and reflexes directly to germline sequencing without the BRAF and methylation gate.
On the combined MSH2 and MSH6 pattern, the germline test must include EPCAM, because three-prime EPCAM deletions silence the MSH2 promoter and mimic a primary MSH2 mutation.
Choose the multi-gene panel by dominant clinical phenotype, and require pre-test counseling before drawing blood because positive, negative, and uncertain results all carry consequences.
Once a pathogenic variant is confirmed in the proband, prioritize cascade testing of first-degree relatives, each of whom is fifty-fifty at risk and carries the same surveillance program.

Study the full chapter on Board Pearls, with practice questions, tables and primary-guideline references: Hereditary GI Cancer Syndromes
Read this episode: boardpearls.com/gi/episodes/hereditary-gi-cancer-syndromes-ep1
Questions or feedback: [email protected].
(00:00) - The framework runs on tumor biology
(00:57) - Universal four-protein immunohistochemistry
(01:30) - Endometrial IHC and the sentinel cancer
(02:04) - The reflex pathway by IHC pattern
(02:19) - MLH1 and PMS2 loss, the sporadic gate
(04:19) - EPCAM in the MSH2 differential
(05:33) - Multi-gene panels and phenotype overlap
(06:59) - Referral and keeping surveillance from lapsing
...more
10min
July 16, 2026Chapter 35, Ep 6 of 6: Post-Bariatric Pregnancy and Biliary Disease
Episode six closes the chapter on two luminal problems governed by anatomy and timing. Post-bariatric pregnancy reads every rule off what the surgery changed: bypassed duodenum drops iron and calcium, reduced parietal cell exposure drops B12, the bypassed pylorus invalidates the OGTT, and mesenteric defects plus a gravid uterus produce internal hernia, so right upper quadrant pain after gastric bypass is internal hernia until proven otherwise. Cholelithiasis is governed by the trimester window: conservative when mild, second-trimester laparoscopic cholecystectomy when complicated, and ERCP built around keeping fetal dose under one milligray.

Topics covered
Anatomy and timing as the organizing logic
Post-bypass malabsorption pattern
Gestational diabetes screening after bypass
Internal hernia emergency
Marginal ulcers after RYGB
Cholelithiasis and the trimester window
ERCP and radiation minimization
Antibiotic selection

Key decisions
Conception is delayed twelve to twenty-four months after bariatric surgery because the rapid weight-loss phase and unrepleted micronutrient stores create a compromised environment for fetal growth.
Micronutrient supplementation is mandatory through pregnancy after bypass and sleeve, with B12, iron, folate, calcium, vitamin D, and thiamine all followed and adjusted.
The oral glucose tolerance test is avoided after Roux-en-Y because the bypassed pylorus produces dumping that makes the curve uninterpretable, and fasting glucose with home monitoring replaces it.
Severe right upper quadrant pain in a post-Roux-en-Y patient in late pregnancy is internal hernia until ruled out, and CT with abdominal shielding is appropriate because missing it allows incarcerated bowel necrosis within hours.
Mild biliary colic is managed conservatively, while recurrent colic, complicated cholelithiasis, or gallstone pancreatitis goes to laparoscopic cholecystectomy in the second trimester where all three windows align.
ERCP is reserved for cholangitis, persistent obstruction, or a large stone with refractory symptoms, and keeps fetal dose under one milligray using limited pulsed fluoroscopy, lead shielding, and non-fluoroscopic cannulation when feasible.
Fluoroquinolones and tetracyclines are avoided for their fetal tissue targets, and beta-lactam plus beta-lactamase inhibitor or cephalosporin plus metronidazole are the appropriate antibiotic choices.

Study the full chapter on Board Pearls, with practice questions, tables and primary-guideline references: GI in Pregnancy
Read this episode: boardpearls.com/gi/episodes/gi-in-pregnancy-ep6
Questions or feedback: [email protected].
(00:00) - Anatomy and timing as the logic
(01:11) - Post-bypass malabsorption pattern
(02:15) - Gestational diabetes screening after bypass
(03:06) - Internal hernia emergency
(04:41) - Marginal ulcers after RYGB
(05:50) - Cholelithiasis and the trimester window
(07:14) - ERCP and radiation minimization
(08:56) - Antibiotic selection
...more
13min
July 16, 2026Chapter 35, Ep 5 of 6: Inflammatory Bowel Disease in Pregnancy
Episode five flips a deeply intuitive instinct: pregnancy is not the time to back off immunosuppression, because the measured danger to the fetus is active maternal disease, not active maternal medicine. Once that principle is in place the medication rules become predictable, anything that maintained remission is continued and a small set of mechanism-toxic drugs is held. The molecular centerpiece is FcRn-mediated placental transfer, which loads IgG anti-TNF into cord blood by term but spares the Fab-fragment certolizumab, and that fact drives dose timing near term and infant vaccine decisions.

Topics covered
Active disease as the fetal danger
The central teaching against backing off
The safe-to-continue drugs
FcRn placental transfer and certolizumab
Dose timing near term
Infant live virus vaccination
The contraindicated drugs
Assessing disease activity in pregnancy

Key decisions
Biologic therapy is continued through delivery rather than held in the third trimester, because active disease at conception, not the medication, is what predicts adverse pregnancy outcomes.
Sulfasalazine requires folic acid supplementation bumped to two to three milligrams daily because the sulfa moiety antagonizes folate, and thiopurines are safe because the fetal liver cannot activate the prodrug.
Infliximab, adalimumab, and golimumab are IgG antibodies that cross via FcRn so cord levels can exceed maternal by term, while certolizumab is a Fab fragment with no Fc region and minimal transfer in any trimester.
For IgG anti-TNF agents the final dose is often spaced to roughly week thirty-two through thirty-eight so birth occurs at trough, and the biologic is resumed twenty-four hours after vaginal or forty-eight hours after cesarean delivery.
Live virus vaccination such as rotavirus was conservatively delayed six to twelve months in IgG-biologic-exposed infants, though the 2025 consensus now permits rotavirus for anti-TNF, IL-23 inhibitor, and vedolizumab exposure.
Methotrexate is absolutely contraindicated and stopped three to six months before conception, and tofacitinib, JAK inhibitors, ozanimod, thalidomide, and rifaximin are avoided.
CRP is unreliable in pregnancy because it rises physiologically, so fecal calprotectin is used for activity assessment and a C. difficile stool test is sent whenever a flare presentation comes through the door.

Study the full chapter on Board Pearls, with practice questions, tables and primary-guideline references: GI in Pregnancy
Read this episode: boardpearls.com/gi/episodes/gi-in-pregnancy-ep5
Questions or feedback: [email protected].
(00:00) - Active disease as the fetal danger
(00:27) - The central teaching against backing off
(01:58) - The safe-to-continue drugs
(02:59) - FcRn transfer and certolizumab
(04:00) - Dose timing near term
(04:48) - Infant live virus vaccination
(05:54) - The contraindicated drugs
(06:48) - Assessing disease activity in pregnancy
...more
10min
July 16, 2026Chapter 35, Ep 4 of 6: Incidental and Pre-Existing Liver Disease
Episode four takes the hepatic disease that is not caused by pregnancy but is reshaped by it. Viral hepatitis turns on virus-specific decisions: the tenofovir-plus-HBIG-and-vaccine stack that decisively cuts HBV vertical transmission, universal HCV screening with treatment deferred, genotype-driven HEV severity, and the empiric acyclovir that any pregnant patient with high transaminases and low bilirubin earns before HSV PCR returns. The pre-existing diseases follow an immune and pharmacokinetic principle: continue what is working and swap out the teratogens, with the specifics being mycophenolate out, azathioprine acceptable, trientine over penicillamine, and propranolol not nadolol.

Topics covered
Hepatitis A and vaccination safety
Hepatitis B and the tenofovir decision
Hepatitis C and universal screening
Hepatitis E and genotype severity
Disseminated HSV and empiric acyclovir
Autoimmune hepatitis and PBC continuation
Wilson disease and chelation
Cirrhosis and portal hypertension

Key decisions
Maternal antiviral therapy for hepatitis B is added when HBV DNA exceeds two hundred thousand international units per milliliter by week twenty-eight, using tenofovir disoproxil fumarate three hundred milligrams daily started at twenty-eight to thirty-two weeks.
All infants of HBsAg-positive mothers receive HBIG plus the first vaccine dose within twelve hours of birth, taking transmission from over ninety percent down to under five percent, and cesarean delivery is not indicated for HBV alone.
Ribavirin is essentially absolutely contraindicated as a teratogen requiring two forms of contraception for six months, and HCV is screened universally but treated before conception or after pregnancy, while hepatitis E genotypes one and two carry twenty to thirty-three percent third-trimester maternal mortality by geography.
Disseminated HSV produces anicteric liver failure with transaminases twenty-five to forty times normal and bilirubin below three, and empiric IV acyclovir is started before PCR returns because it cuts mortality from thirty to fifty percent down to eight to twenty-five percent.
Azathioprine is continued because the fetal liver cannot activate it, while mycophenolate is strictly contraindicated with a six-month pre-conception washout, and methotrexate-class exposure is avoided.
In Wilson disease chelation must continue with trientine preferred over penicillamine, the dose reduced twenty-five to fifty percent in the third trimester, copper IUDs contraindicated, and levonorgestrel IUDs preferred.
For variceal prophylaxis in cirrhotic pregnancy propranolol is preferred over nadolol, and vasopressin is avoided because it activates myometrial V1 receptors and induces contractions.

Study the full chapter on Board Pearls, with practice questions, tables and primary-guideline references: GI in Pregnancy
Read this episode: boardpearls.com/gi/episodes/gi-in-pregnancy-ep4
Questions or feedback: [email protected].
(00:00) - The incidental half and hepatitis A
(00:34) - Virus-specific decisions begin
(01:21) - Hepatitis B and the tenofovir decision
(04:18) - Hepatitis C and universal screening
(05:54) - Hepatitis E and genotype severity
(07:23) - Disseminated HSV and empiric acyclovir
(08:45) - Pre-existing liver disease principles
(11:50) - Wilson disease and chelation
(14:15) - Cirrhosis and portal hypertension
...more
19min
July 16, 2026Chapter 35, Ep 3 of 6: Pregnancy-Specific Liver Diseases
Episode three covers the liver diseases that exist only because pregnancy is occurring, the syndromes for which delivery is the definitive treatment. It opens on intrahepatic cholestasis, where a stillbirth-risk curve inflecting at bile acids of one hundred drives delivery timing and a normal GGT separates it from obstruction. It then works through the preeclampsia, HELLP, and AFLP spectrum, teaching the distinction as a mechanism problem: vascular fibrin-and-shear versus fetal LCHAD-driven mitochondrial overwhelm. It closes on hepatic capsular rupture, the catastrophic complication that hemodynamic status triages.

Topics covered
The two halves of liver disease in pregnancy
Intrahepatic cholestasis and its genetics
Diagnosis and the normal-GGT discriminator
Ursodeoxycholic acid treatment
Bile-acid-stratified delivery timing
Preeclampsia and HELLP
AFLP and the LCHAD mechanism
Hepatic rupture as the catastrophe

Key decisions
Intrahepatic cholestasis is diagnosed at total bile acids above ten micromol per liter, and a normal GGT with elevated bile acids and transaminases discriminates it from obstructive cholestasis, which lifts GGT and prompts ultrasound and MRCP.
Ursodeoxycholic acid ten to fifteen milligrams per kilogram per day is the treatment, with cholestyramine as second-line, and vitamin K is given around delivery because cholestasis impairs fat-soluble vitamin absorption.
Delivery timing follows the bile-acid tier: below forty deliver at thirty-nine weeks, forty to ninety-nine between thirty-six and thirty-nine, and at or above one hundred at thirty-six to thirty-seven weeks because stillbirth risk inflects sharply.
HELLP is defined by the Tennessee criteria of LDH at or above six hundred, AST at or above seventy, and platelets at or below one hundred thousand, and twenty percent of cases occur without hypertension.
Preeclampsia and HELLP are treated by delivery because the placental endothelial dysfunction does not resolve until the placenta is gone, with magnesium for seizure prophylaxis and platelet transfusion to above forty thousand for delivery.
AFLP is separated from HELLP by looking for mitochondrial failure, hypoglycemia, encephalopathy, coagulopathy, and lactic acidosis with an AST-to-ALT ratio above one, versus HELLP's schistocytes, high LDH, and deep thrombocytopenia.
Hepatic capsular rupture is triaged by hemodynamics: an unstable patient gets resuscitation with surgery or hepatic artery embolization, while a stable contained hematoma is managed conservatively with coagulopathy correction and serial imaging.

Study the full chapter on Board Pearls, with practice questions, tables and primary-guideline references: GI in Pregnancy
Read this episode: boardpearls.com/gi/episodes/gi-in-pregnancy-ep3
Questions or feedback: [email protected].
(00:00) - The two halves of liver disease in pregnancy
(01:02) - Intrahepatic cholestasis and its genetics
(02:53) - Diagnosis and the normal-GGT discriminator
(04:11) - Ursodeoxycholic acid treatment
(06:22) - Bile-acid-stratified delivery timing
(08:05) - Preeclampsia and HELLP
(11:19) - AFLP and the LCHAD mechanism
(16:00) - Hepatic rupture as the catastrophe
...more
20min
July 16, 2026Chapter 35, Ep 2 of 6: GERD and Peptic Ulcer Disease
Episode two takes the upper-GI symptom that rides on the same pregnancy physiology as hyperemesis. GERD dominates because progesterone loosens the lower esophageal sphincter while estrogen strengthens the gastric mucosal barrier, so ulcers stay uncommon. The management is a stepwise sequence built on local-then-systemic safety logic, and the reasoning is that the rules fall out of mechanism rather than memorization. The one hard contraindication anchors the section: misoprostol is off the table because the same prostaglandin effect that heals ulcers induces labor.

Topics covered
Why heartburn dominates in pregnancy
Lifestyle and mechanical first measures
Local-acting antacids and alginates
Sucralfate as a non-absorbed add-on
Famotidine as the preferred H2 blocker
Proton pump inhibitors and the omeprazole detail
Misoprostol contraindication
Endoscopy for alarm features

Key decisions
Calcium carbonate is the preferred antacid because it neutralizes acid without aluminum or sodium bicarbonate, and aluminum-only antacids and sodium bicarbonate are avoided for fetal aluminum and maternal alkalosis concerns.
Famotidine is the preferred H2 blocker on class-specific safety, while ranitidine is withdrawn for NDMA and cimetidine is avoided for antiandrogenic and P450 effects.
The PPI panel was largely category B, and omeprazole is the one historical category-C detail even though it carries the longest pregnancy track record.
Misoprostol is prohibited in pregnancy for reflux or peptic disease because it is a prostaglandin E1 analog that produces uterine contractions.
New dyspepsia in pregnancy is usually GERD, but dyspepsia with iron deficiency anemia or melena warrants endoscopic evaluation regardless of trimester.
H. pylori testing and treatment are deferred to postpartum unless complicated peptic ulcer disease forces the issue, because standard quadruple regimens contain agents problematic in pregnancy.
Endoscopy is reserved for alarm features and timed to the second trimester, with benzodiazepine sedation minimized in the first trimester for cleft lip and palate concerns.

Study the full chapter on Board Pearls, with practice questions, tables and primary-guideline references: GI in Pregnancy
Read this episode: boardpearls.com/gi/episodes/gi-in-pregnancy-ep2
Questions or feedback: [email protected].
(00:00) - Introduction and the safety-tiered sequence
(00:37) - Why heartburn dominates in pregnancy
(01:06) - Local-acting antacids and alginates
(01:53) - Sucralfate as a non-absorbed add-on
(02:40) - Famotidine as the preferred H2 blocker
(03:24) - PPIs and the omeprazole detail
(04:13) - Misoprostol contraindicated
(05:51) - Endoscopy for alarm features
...more
8min

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