INTRODUCTION: Bowel movement (BM) frequency is used to titrate lactulose for hepatic encephalopathy (HE). However, stool consistency using the Bristol stool scale (BSS, 0-7) is often ignored.

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The effects of hypothyroidism on the liver are not well understood. A 77-year-old woman with Hashimoto's thyroiditis had stopped taking levothyroxine on her own for 6 months. Her thyroid stimulating hormone (TSH) level was consistent with severe hypothyroidism. She resumed thyroid replacement therapy. The following month, her liver function tests were significantly elevated. Seven weeks after resumption of therapy, her TSH and liver tests had returned to normal. We attribute the mixed hepatocellular injury to hypothyroidism that resolved on correction of the hypothyroid state. This case reminds us that thyroid disease should be considered when evaluating acute liver injury.

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Background: The interaction between IBD and psychosocial health is poorly understood. The prevalence of depression in IBD is three times higher than in the general population. Objective: We assessed the prevalence of and risk factors for developing depression in a tertiary care outpatient setting. A secondary objective was to assess adherence to recommended depression screening. Methods: We collected data from patients seen in the outpatient IBD clinic at the MedStar Georgetown University Hospital (MGUH) from August 2017 to March 2018. All patients were supposed to be screened for depression with the patient health questionnaire (PHQ-2). A score of score ≥3 was consistent with depression and prompted the provided to complete a PHQ-9 questionnaire. Patients who were under the age of 18 years were excluded. Results: We included 201 (CD) patients and 169 (UC) patients who had PHQ-2 data available. Only 55% (370 of 676) of patients had a documented PHQ-2 score. The prevalence of depression in this study was 3% (11 of 370). There were no significant differences observed between CD and UC patients in regards to gender, age, disease duration, race, or presence of depression. Depression did not vary based on disease severity (p=0.13 for CD, p=0.62 for UC). Conclusions: The prevalence of depression in this cohort is less than in the general population (6.7%). The majority of patients had CD, smoke, have an ostomy, had IBDrelated surgery, and were in remission. Patients with depression should be identified early and referred for therapy, because left untreated, depression can lead to aggressive disease.

Purpose of review Although gut dysbiosis can hasten disease progression in end-stage liver disease and contribute to disease severity, morbidity and mortality, its impact during and after transplant needs further study. Recent findings Changes in the microbiome are associated with hepatic decompensation. Immune homeostasis is further disrupted during transplant and with immunosuppressants required after transplant. There is increasing evidence of the role of microbiota in peri and posttransplant complications. Summary Although transplant is highly successful with acceptable survival rates, infections, rejection, disease recurrence and death remain important complications. Prognostication and interventions involving the gut microbiome could be beneficial.

In recent years, gastroenterology has become one of the most competitive subspecialties included in the internal medicine fellowship match, which increases the stressful nature of an already potentially nerve-wracking process for the trainee. Though each applicant has unique strengths and thus the process is somewhat individualized, there are some basic principles that can render an applicant more competitive for a gastroenterology fellowship. These include establishing mentorship, achieving scholarly work, building your resume, honing interpersonal and networking skills, and writing a well-planned application. The goal of this article is to outline some basic principles that will help improve the competitiveness of an applicant, and also highlight some practical tips and tricks for applicants with diverse backgrounds, such as international medical graduates, minority applicants, and women in medicine.

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