January 09, 2014 Home|Journals & Publications|  AGA eDigest
AGA eDigest

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FDA Warns of Possible Harm from OTC Constipation Meds

The U.S. FDA is warning that using more than one dose in 24 hours of over-the-counter (OTC) sodium phosphate drugs to treat constipation can cause rare but serious harm to the kidneys and heart, and even death.

OTC sodium phosphate drug products include oral solutions taken by mouth and enemas used rectally. FDA has become aware of reports of severe dehydration and changes in the levels of serum electrolytes from taking more than the recommended dose of OTC sodium phosphate products, resulting in serious adverse effects on organs, such as the kidneys and heart, and in some cases resulting in death. These serum electrolytes include calcium, sodium and phosphate. According to the reports, most cases of serious harm occurred with a single dose of sodium phosphate that was larger than recommended or with more than one dose in a day.

Encourage your patients to read the drug facts label for OTC sodium phosphate drugs and use these products as recommended on the label, and not exceed the labeled dose. Health-care professionals should use caution when recommending an oral dose of these products for children 5 years and younger. The rectal form of these products should never be given to children younger than 2 years. 

More information is available in the FDA Consumer Update.


Diverticulitis Has Low Rate of Digression

Colonic diverticulosis is the most common finding during routine colonoscopy, and patients often question the significance of these lesions. Guidelines state that these patients have a 10 to 25 percent lifetime risk of developing acute diverticulitis. However, this value was determined based on limited data, collected before population-based colonoscopy, so the true number of cases of diverticulosis was not known. Kamyar Shahedi and colleagues report in Clinical Gastroenterology and Hepatology that, based on a study of the Veterans Affairs Greater Los Angeles Healthcare System, only about 4 percent of patients with diverticulosis develop acute diverticulitis, contradicting the common belief that diverticulosis has a high rate of progression. Researchers also found that younger patients have a higher risk of diverticulitis, with risk increasing per year of life. These results can help inform patients with diverticulosis about their risk of developing acute diverticulitis.

Clinical Gastroenterology and Hepatology 2013: 11(12): 1609-1613

A Diet Low in FODMAPs Reduces Symptoms of IBS

A diet low in fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs) often is used to manage functional gastrointestinal symptoms in patients with IBS, yet there is limited evidence of its efficacy, compared with a normal Western diet. Emma P. Halmos and colleagues investigated the effects of a diet low in FODMAPs compared with an Australian diet, in a randomized, controlled, single-blind, cross-over trial of patients with IBS. They report in Gastroenterology that a diet low in FODMAPs effectively reduced functional gastrointestinal symptoms. This high-quality evidence supports its use as a first-line therapy.

Gastroenterology 2014: 146(1): 67-75.e5

Identification and Manipulation of Biliary Metaplasia in Pancreatic Tumors

Metaplasias often have characteristics of developmentally related tissues. Pancreatic metaplastic ducts are usually associated with pancreatitis and pancreatic ductal adenocarcinoma. The tuft cell is a chemosensory cell that responds to signals in the extracellular environment via effector molecules. Commonly found in the biliary tract, tuft cells are absent from normal murine pancreas. Using the aberrant appearance of tuft cells as an indicator, Kathleen E. DelGiorno and colleagues tested if pancreatic metaplasia represents transdifferentiation to a biliary phenotype and what effect this has on pancreatic tumorigenesis. They report in Gastroenterology that expression of KrasG12D and SOX17 in mice induces development of metaplasias with a biliary phenotype containing tuft cells. Tuft cells express a number of tumorigenic factors that can alter the microenvironment. Expression of SOX17 induces pancreatitis and promotes KrasG12D-induced tumorigenesis in mice.

Gastroenterology 2014: 146(1): 233-244.e5


Implementation Delay in Two ASC GI Measures

CMS is notifying ambulatory surgical center (ASC) program facilities that it will delay the implementation of the following GI chart-abstracted measures newly finalized for inclusion in the Ambulatory Surgical Center Quality Reporting (ASCQR) Program:  

  • ASC-9: Endoscopy/Polyp Surveillance: Appropriate follow-up interval for normal colonoscopy in average risk patients
  • ASC-10: Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use

These measures will be implemented with a three-month deferral; data collection will commence with April 1, 2014, encounters. The 2015 calendar year (CY) reporting periods will not change from what has been previously finalized in the CY 2014 Hospital Outpatient Prospective Payment System/ASC Final Rule published in the Federal Register on Dec. 10, 2013 (78 FR 75137). Please refer to the table below for the schedule of these measures for the CY 2016 payment determination. 

CMS published the specifications for the newly finalized measures in the Dec. 31, 2013, Addenda to the Specifications Manuals for the ASC Program.  

New Collection Schedule:

Program Encounter dates Reporting period (window) Payment determination
ASCQR Apr. 1–Dec. 31, 2014 (Q2-Q4, 2014) Jan. 1–Aug. 15, 2015 CY 2016

Please contact the ASC Quality Reporting Support Contractor at 1-866-800-8756 or at https://cms-ocsq.custhelp.com for questions concerning the ASCQR Program or if additional information and/or assistance are needed. 

IBS Brochure Helps Educate, Spread Awareness

Help educate your IBS patient and spread awareness with AGA's free brochure "IBS: A Patient’s Guide to Living with Irritable Bowel Syndrome." According to NIDDK, IBS is estimated to affect between 3 and 20 percent of the American population, making it one of the most common GI disorders diagnosed by physicians.

The brochure is designed to give IBS sufferers — and the general public — facts about IBS, a better understanding of the disorder and a starting point for discussions with their physician.

The 10-page brochure covers a variety of topic areas, including:

  • Living with IBS.
  • Causes of IBS.
  • Symptoms and diagnosis.
  • IBS triggers.
  • Treatment.

Also included in the brochure are a symptom tracker chart and a notes and patterns section. Physicians can order the brochure from the AGA free of charge. Brochures come pre-packaged in sets of 25. Learn more and place an order.

This brochure is supported by educational grants from Forest Laboratories, Inc. and Ironwood Pharmaceuticals, Inc.

Thiopurine Use Ups Risk of Skin Cancer for Ulcerative Colitis Patients

Current thiopurine use is an independent risk factor for nonmelanoma skin cancer in patients with ulcerative colitis, according to a study highlighted in GI & Hepatology News.

In the retrospective cohort study of more than 14,000 U.S. veterans with ulcerative colitis, current users of thiopurines were more than twice as likely as never users to receive a diagnosis of squamous or basal cell skin cancer. The excess risk, however, disappeared after stopping thiopurines.

It is crucial that physicians educate patients about the risk of nonmelanoma skin cancer and possible preventive measures. For more information, read the GI & Hepatology News article.


Gut Microbiota for Health World Summit — 2014

Join a prestigious faculty of researchers and clinicians to gain a firm understanding of the key role gut microbiota play in digestion, metabolism and immune function. You will be able to address how changes in the biodiversity of gut microbiota are associated with far-reaching consequences on host health and development. The summit also provides an opportunity to examine how therapeutic interventions such as diet, functional foods and fecal microbiota transplantation have yielded some success in treating GI disorders.

Discussion-based workshops will allow you to directly engage faculty and further investigate select topics such as gut-brain axis, gas and IBS, probiotics and prebiotics in pediatrics, and more.

The summit will be held at the Hilton Miami Downtown, March 8 and 9, 2014. 

The summit is co-sponsored by the AGA Institute and the European Society of Neurogastroenterology and Motility. Funding for the summit is provided by Danone Dairy.

To register for the summit and view the program, visit www.gastro.org/gutsummit.

Your Gifts Support Gut Microbiota and Diet Research

imgYour AGA Research Foundation gifts support Andrew T. Chan from Massachusetts General Hospital, who received the 2013 AGA-Elsevier Gut Microbiome Pilot Research Award.

“As a gastroenterologist and trained epidemiologist, my research focus is on diet and lifestyle factors in relation to the etiopathogenesis of digestive diseases, including colorectal cancer (CRC) and IBD. Over the last decade, I have been a principal investigator in long-running population-based cohorts in which we have collected prospective diet, lifestyle, genetic and biomarker data to establish an unprecedented resource for the study of CRC and IBD. Recently, there has been an explosion of data supporting the critical role that gut bacteria play in the development of CRC and IBD. However, how specific bacteria or the byproducts of their metabolism are associated with disease is not yet well-understood. Specific dietary components alter the composition and function of gut bacteria, and gut bacteria in turn ferment and metabolize dietary factors. Thus, further studies, particularly relating both short-term and long-term diet, to the gut microbiome are needed.”

“With the support of this AGA-Elsevier Pilot Award, we will conduct a pilot investigation of the impact of diet on gut microbiota within our prospective cohorts. We will apply a cutting edge microbial profiling and computational analysis pipeline to multiple gut microbiome samples to focus on the influence of diet on specific candidate organisms, genes and pathways associated with digestive diseases. We anticipate that the results of this pilot study will lead to several additional follow-up studies that will form the basis of more substantial grant applications. These include 1) follow-up studies of specific candidate bacteria, genes and pathways in mouse models to further understand specific disease causative mechanisms; 2) more extensive sequencing of microbiome samples from this cohort to relate other dietary and lifestyle factors with gut bacteria; 3) larger scale collections of microbiome samples from our cohorts as the basis for long-term prospective studies linking diet, lifestyle and gut bacteria with the development of chronic disease.”

To make a donation to the AGA Research Foundation, visit www.gastro.org/contribute.

January Research Award Deadlines

Start your new year by securing research funding for your upcoming projects. Don't miss the deadline to apply for awards offered by the AGA Research Foundation. There are several deadlines coming up this month. Apply today for:

There are also several deadlines in February, including the AGA Investing in the Future Student Research Fellowship (due on Feb. 7). Complete information about these and other research awards are available on the AGA website.

Memorial and Honorary Gifts: A Special Tribute

Did you know that you can honor a family member, friend or colleague whose life has been touched by GI research through a gift to the AGA Research Foundation? Your gift will honor a loved one and support the AGA Research Awards Program while giving you a tax benefit; any charitable gift can be made in honor or memory of someone. 

A Gift Today
An outright gift will help fund the AGA Research Awards Program. Your gift will assist in furthering basic digestive disease research, which can ultimately advance research into all digestive diseases. The financial benefits include an income tax deduction and possible elimination of capital gains tax. A cash gift of $25,000 or more qualifies for membership in the AGA Legacy Society, which recognizes the foundation’s most generous individual donors. 

A Gift Through Your Will or Living Trust
You can include a bequest in your will or living trust stating that a specific asset, certain dollar amount or — more commonly — a percentage of your estate will pass to the AGA Research Foundation at your death in honor of your loved one. A bequest gift of $50,000 or more qualifies for membership in the AGA Legacy Society. 

For more information on how to give and recognize your loved one, visit www.gastro.org/contribute or contact Stacey Hinton Tuneski at 301-222-4005 or stuneski@gastro.org.


Trainee Track at DDW® 2014 Designed for Young GIs

AGA has developed special sessions at DDW® 2014 to meet the unique needs of physicians who are new to the field. Participants will learn about all aspects of starting a career in clinical practice or research, have the opportunity to network with mentors and peers, and review board material.

With the exception of the AGA Spring Postgraduate Course, all of the sessions are free, but you must register for DDW to attend. Registration is open now for AGA members and is free for trainees through March 26.

  • AGA Spring Postgraduate Course: Best Practices at the Bedside: Critical Thinking for Common Conditions — Saturday, May 3, and Sunday, May 4
    Learn from the foremost experts on GI and hepatology and exercise your mind on the latest information in practical use for the clinician at the bedside of the patient. Trainees may register at a reduced registration fee.
  • Mentor and Advisor Program: Reception for Trainees/Young GIs: An Evening with AGA Mentors — Saturday, May 3
    Meet your peers and more established colleagues who serve as mentors, while enjoying refreshments.
  • Board Review Session — Monday, May 5
    This session, designed around content from DDSEP® 7, serves as a primer for third-year fellows preparing for the board exam as well as a review course for others wanting to test their knowledge. Discount coupons for DDSEP 7 will be offered on a first-come, first-served basis.
  • Career and Professional Related Issues — Monday, May 5
    Get advice on common career issues such as choosing a practice type and location, developing your CV, interviewing, negotiating contracts, and work-life balance.
  • Preparing Yourself for Life After Fellowship — Monday, May 5
    Attendees will be provided with information on measures that ensure successful transition from fellowship to a career in gastroenterology. A designated portion of the session will illustrate the importance of career opportunities within fellowship training as well as the benefits (short and long term) gained from mentor-mentee relationships.
  • The Next Accreditation System (NAS) and Milestones: Advice for Fellows and Faculty — Monday, May 5
    Attendees will be provided with pertinent information on milestones and how they relate to GI fellowship training, as well as new requirements associated with the Next Accreditation System (NAS). A summary of changes regarding the NAS and how it relates directly to fellows and faculty will be presented.

Visit the AGA website for additional details about Trainee Track sessions.

Find a Mentor This Year and Advance Your Career

Make 2014 the best year yet by finding a mentor that can give you advice and suggestions throughout the year. The Mentor and Advisor Program, AGA Institute’s free online advice service, will help you do just that.

The program consists of more than 20 senior AGA members who have offered to provide informal mentoring to gastroenterologists at any career stage. Through this forum, AGA members can confidentially submit questions to a specific mentor. Mentors may be experts in a desired subject matter or even a director of a GI training program.

To find a mentor, visit AGA's website and browse the list of participating members. You can send a confidential message to the mentor of your choice through the site. AGA staff will monitor the program to ensure that the mentor receives the message and that he or she responds to you within two business days.


Present Your New Medical Technology at the 2014 AGA Technology Summit

Interact directly with representatives from the FDA, CMS and other key stakeholders to get answers to specific questions you may have regarding developing and obtaining adoption and coverage for new medical technologies. Unmet needs and clinical and research opportunities will also be discussed in areas such as endoscopic mucosal resection.

Do not miss your opportunity to support and stimulate investment and innovation in the development and delivery of new GI technologies. 

The AGA Technology Summit was developed in collaboration with Kleiner Perkins Caufield & Byers (KPCB) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES).

Register for the summit.

Technology Presentations
Entrepreneurs with an innovative technology or FDA-regulated product looking to get it financed, licensed or distributed are encouraged to apply for an opportunity to present at the 2014 summit. A panel of business development leaders, investors, entrepreneurs and other strategic partners will provide valuable feedback. Submit an application.

Corporate Sponsors
The AGA Institute, KPCB and SAGES gratefully acknowledge the following industry partners for the 2014 summit.

Diamond Level: Boston Scientific and PENTAX Medical
Platinum Level: Covidien
Gold Level: EndoGastric Solutions
Silver Level: Apollo, Given Imaging, Mauna Kea Technologies and Mederi
Bronze Level: Cook Medical, Crospon, EndoChoice and Medigus


Online Registration for the 2014 Clinical Congress Ends Jan. 10

Register today to secure your place at the 2014 AGA Clinical Congress. The last day to register online and save is Friday, Jan. 10. Physicians are eligible to receive eight MOC points for attending the congress.

Led by a prestigious faculty of internationally recognized clinicians, you will be immersed in an interactive, case-based program to discuss cutting-edge clinical updates such as:

  • Fecal transplantation for C. difficile.
  • Mucosal healing in IBD.
  • FODMAP diet.
  • Biologic therapy in IBD.
  • Serrated adenomas, and more.

Panel discussions will take place following each session, incorporating an audience response system to present and discuss case-based scenario questions. You can use your smartphone or tablet to answer questions during each session, view how your peers answer questions and take advantage of the faculty's expertise in engaging, real-life cases. 

Register now

The 2014 Clinical Congress is supported in part by educational grants from: AstraZeneca, GiHealth Foundation, Gilead, Given Imaging and Janssen Biotech.

GastroSlides Focus on Cirrhosis and Portal Hypertension

GastroSlides offers a comprehensive, growing collection of images on major GI and liver disease topics. Developed by internationally renowned authors, the images are a valuable resource to help you create high-quality presentations that explain the complex concepts and processes of digestive diseases.

This month's images focus on the causes, diagnosis and management of cirrhosis and its most common complication — portal hypertension — and are separated into the following sections:

  • Part I: Cirrhosis: Definition, Natural History and Diagnosis
  • Part II: Pathophysiology and Types of Portal Hypertension
  • Part III: Hyperdynamic Circulatory State
  • Part IV: Varices and Variceal Hemorrhage
  • Part V: Ascites
  • Part VI: Spontaneous Bacterial Peritonitis
  • Part VII: Hepatorenal Syndrome
  • Part VIII: Hepatic Encephalopathy
  • Part IX: Hepatopulmonary Syndrome
  • Part X: Portopulmonary Hypertension
  • Part XI: Liver Transplant

Order these slides individually as you need them or purchase a one-year subscription and have access to the entire GastroSlides library of more than 4,000 images. Preview and order slides.

Special offer: get your free download of the GastroSlides unit on liver cancer (revised).

GastroSlides is a continuing education resource directed by the AGA Institute Education and Training Committee.


New Journal Podcasts Available

Download the latest journal podcasts on popular articles from Gastroenterology and Clinical Gastroenterology and Hepatology (CGH).

Recent podcasts from Gastroenterology include:

Recent podcasts from CGH include:

Each podcast lasts approximately 10 to 15 minutes and can be downloaded to an iPod or any other media player. Podcasts are available through iTunes. Subscription to the podcasts is free and you will receive automatic updates on your iPod as new podcasts are added.

Multiple Elevated Red Spots in a Woman with Nausea, Altered Stools and Weight Loss

The January issue of Clinical Gastroenterology and Hepatology features the case of a 69-year-old woman presented with nausea, diminished appetite, 9 kilograms of weight loss in six months and altered stools. Her stools were loose without loss of blood or mucus. She had multiple skin lesions on the trunk, vulva and vagina. Because of gastrointestinal complaints, the patient underwent a gastroduodenoscopy.

Along the duodenum, multiple small mucosal nodules with subtle central ulceration were seen; in the stomach, some comparable lesions were visible. Colonoscopy and videocapsule-endoscopy showed the same elevated light red lesions spread throughout the colon, most marked in the rectosigmoid, and along the entire small intestine (Figures A and B).

On pathologic examination, a mixed infiltration with an accumulation of histiocytes with many neutrophils and a few eosinophils was seen (Figure C). Immunohistochemically, the cells stained strongly positive for CD1a (Figure D) and CD4, and weakly positive for S-100 and CD68. Histopathologic findings of the skin biopsy specimen showed an identical infiltration with histiocytes and neutrophils.

The diagnosis of Langerhans cell histiocytosis (LCH) was made based on the spreading infiltration of histiocytes, immunohistochemically positive for CD1a and S100. LCH is a rare disease, seen in both children and adults. It affects various organs and has a widespread pattern of signs and symptoms. In adults, the estimated incidence is one or two cases per million. The etiology of LCH still is unknown. The Langerhans cells are believed to originate from hematopoietic stem cells, which express CD1a and/or S100. Because the literature reports fewer then 20 adult cases, it is assumed that gastrointestinal LCH is underestimated. Notably, most reported adult cases present as solitary polyps. In adults, skin lesions associated with extensive involvement of the small and large intestine is seldom seen.

The patient was treated with prednisolone and vinblastine according to the LCH-A1 multicentre study program, complicated by polyneuropathy. Because there was multi-organ involvement, the patient was maintained on therapy with daily 6-mercaptopurine and prednisolone for five days once every three weeks. Three months later, her symptoms improved, and the skin and intestinal lesions diminished. However, complete remission was not achieved.

In conclusion, the authors report an interesting case of LCH in an adult with involvement of the skin and intestinal tract that was responsive to prednisolone, vinblastine and 6-mercaptopurine.

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Place GI Position Listings and Activity Announcements

For as little as $82.50, you can place a classified ad in AGA's weekly email newsletter, AGA eDigest, or AGA's bimonthly magazine, AGA Perspectives. If you place ads in both AGA Perspectives and AGA eDigest, you will receive a 10 percent discount. Advertising in either includes a free online classified listing. Learn more.


Centers for Gastroenterology, P.C., located in beautiful Northern Colorado, is seeking an additional gastroenterologist to join the 11 member practice in the Fort Collins office. Centers for Gastroenterology is a well-established private practice with offices in Fort Collins, Loveland, Greeley and an office staffed part-time in Cheyenne, WY, all together serving a growing population of about 500,000.

We offer a competitive salary and benefits package and an opportunity for partnership status after one year. Experience in ERCP and EUS is considered a plus. Contact: sdubois@digestive-health.net.


Gastroenterology of the Rockies is recruiting a board-certified/board-eligible gastroenterologist to join their successful and thriving practice covering the greater Denver and Boulder areas of Colorado. The group consists of nine board-certified gastroenterologists and four nurse practitioners, located across five clinical sites, which include four physician-owned endoscopy centers and a GI pathology lab.

Requirements: general clinical gastroenterologist; ERCP and advanced fellowship training in EUS are both desirable but not required.

This unique opportunity includes:

  • Partnership track with strong, reputable group.
  • State-of-the-art infrastructure.
  • Fully electronic environment, meaningful use attested.
  • Professionally managed.
  • Outstanding quality of life with easy access to the metropolitan amenities of Denver and the outdoor activities of the Rocky Mountains.
  • Exceptional schools.

For more information about this opportunity please contact:

Dave Green
Email: david.green@gastrorockies.com
Telephone: 970-932-7711


Kaua‘i’s premier multi-specialty group is seeking a BC/BE, fellowship-trained gastroenterologist with excellent clinical and patient relation skills. ERCP experience preferred. Call is 1:3. Kauai Medical Clinic is a 71-physician multispecialty group affiliated with a 71-bed community hospital and Hawaii Pacific Health. 

Combine the advantages of an integrated group practice in a spectacularly beautiful, safe, family-oriented, rural community with the cultural diversity, superb lifestyle, excellent climate and year-round recreational activities of the islands. Competitive salary, benefits and relocation package.

Send/fax CV to:
Helene Oyama
Mail: Kauai Medical Clinic, 3-3420 Kuhio Highway, Suite B, Lihue, HI, 96766-1098
Fax: (808) 246-1645
Phone: (808) 246-2951
Email: hoyama@wilcoxhealth.org 


We are seeking a motivated GI to join our thriving practice. We have a high volume of patients to be seen by an incoming physician. Must be board certified or board eligible. This position is 100 percent gastroenterology. Our practice is located in the Northwest suburbs, 50 miles outside of Chicago. Please send CV to ms.gaims@hotmail.com or fax to 847-382-4429.

North Carolina

Cape Fear Center for Digestive Diseases, a growing gastroenterology practice in Fayetteville, NC, is seeking a full-time BC/BE gastroenterologist. Join a busy practice with five physicians and four mid-level providers that offer outpatient care at our practice-owned endoscopy center, Digestive Health Endoscopy Center. Inpatient care is provided at Cape Fear Valley Health System, the ninth largest health system in the state with 765 patient beds, serving more than 935,000 patients annually.

About the practice:

  • Practice established since 1984. 
  • Offer full range of endoscopy, including ERCP and capsule endoscopy.
  • Practice-owned endoscopy center.

About the position:

  • ERCP experience required, EUS experience a plus.
  • Desirable call arrangement with one hospital.
  • Partnership track with strong, reputable group.
  • State of the art infrastructure.
  • Outstanding quality of life in a family oriented community, with excellent schools and low cost of living.
  • Easy access to beach and mountains.

For more information about this great opportunity, contact:
Rita Graves, Practice Administrator


GI hospitalist needed to join 16 member single-specialty GI group in Southwest Ohio. PA help available to do consults and follow ups. Generous guaranteed salary. Full benefits including malpractice insurance. University town with great suburbs and nationally ranked public as well as private schools, plus affordable housing.

Candidate will perform both outpatient and inpatient procedures in state of the art endoscopy unit. ERCP required and EUS a plus. If interested, contact Marilyn Robinson at mrobinson@digestivespecialists.com or call: 937-396-2767.


An exciting opportunity to join a well-established, highly successful and widely respected practice consisting of five BC gastroenterologists. This independent single-specialty group is located in Green Bay, WI.

  • Extremely competitive compensation with full benefit package.
  • Growing population with 13 percent 65+.
  • Dedicated referral base consisting of 25 clinics and 120+ primary care providers.
  • Secondary referral base consisting of 15 clinics and 31 providers directing the majority of their referrals to this practice.
  • Strong support from 150+ affiliated independent specialists representing all major clinical specialties.
  • Large practice load, excellent income potential and highly motivated group.
  • ERCP advanced and EUS experience is a plus.
  • Call rotation 1:4.

If interested, please contact Dr. David Stampfl:

Email: dstampfl@mac.com
Phone: 920-431-5625 (Office Manager)
Fax: 920-433-7400