Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
Which GI cancer patients do you use oral contrast in staging CT scans?
We do not use oral contrast for most of our patients and only offer oral contrast CT scans for patients we are concerned about perforation.
In patients with GERD, when should Baclofen or alginate-based therapies be considered, and which patient characteristics warrant caution when using these treatments?
Baclofen and alginate-based therapies are adjunctive, phenotype-directed options for actionable GERD symptoms refractory to optimized proton pump inhibitor therapy. Baclofen reduces transient lower esophageal sphincter relaxations and is most effective in regurgitation or belching predominant phenot...
In a patient with unresectable HCC who developed immune-related colitis with the first dose of tremelimumab/durvalumab, would you consider continuing durvalumab alone after resolution of the colitis with steroid treatment?
I haven’t seen too many TREMI/DURVA colitis cases, but basing experience off of BOT/BAL, which is notorious for the CTLA-4 inhibitor-related BOT-colitis, as well as some patients who have had IPI/NIVO colitis, or any grade ≥3 event in the combination setting, it’d be reasonable to continue the PD1/P...
Under what circumstances do you give chemotherapy for a nondiagnostic pancreas biopsy that is suspicious for adenocarcinoma?
Assuming it is a localized pancreatic abnormality and no "metastases," I would not give chemotherapy as such. If anything, I would consider surgical removal, which will also give the exact diagnosis. To start, chemotherapy is not curative (maybe if it were a lymphoma!). There may be some way of doin...
What surveillance is recommended for a C1M3 segment of columnar-lined esophageal mucosa with repeated biopsies demonstrating columnar metaplasia but no goblet cells/intestinal metaplasia across multiple endoscopies?
Based on current U.S. guidelines, routine endoscopic surveillance is not recommended for columnar-lined esophagus without intestinal metaplasia (goblet cells). The American Gastroenterological Association (AGA) does not consider this Barrett's esophagus and does not recommend using that term or perf...
For high-risk ulcer bleeding requiring early anticoagulant resumption, what endoscopic/clinical threshold prompts you to add adjunctive prophylactic hemostatic powder specifically to support earlier restart?
If there is a high-risk ulcer, I would treat it as indicated. If, at the end of treatment (whether with injection + thermal therapy/ clips, etc), I am not confident that I rendered effective treatment, then I would apply hemostatic powder.
Would you use upfront atezo/bev in a patient with HCC and untreated hepatitis?
In the case of a patient with untreated chronic hepatitis C, I would offer upfront atezo/bev, as long as hepatic function is appropriate. At our center, hepatitis C treatment is generally not offered to patients with advanced HCC. Interestingly, only 21% of patients treated with atezolizumab/bevaciz...
Do you refer all of your patients for EGD prior to initiation of atezolizumab/bevacizumab for advanced HCC?
Per the trial, this was required within 6 months of starting the study. However, in practice, I don't know that this strict rule would be necessary. For example, what if an EGD was done 10 months ago without varices? I don't think I would feel strongly about this. Similarly, if we could get one shor...
Do you recommend restarting GLP-1RA after bariatric surgery if they tolerated it before the surgery?
While there are no clear recommendations on whether/when to resume GLP-1 RA after bariatric surgery, current 2025 guideline statements (ASMBS, ADA, AACE, Obesity Society) and expert consensus documents suggest the following approach: Hold GLP-1RA in the acute perioperative period. For daily-dosed ...
How do you decide which GLP-1s to prescribe for obesity?
Unfortunately, it is the insurance companies who are making the decisions about which GLP-1 I can use, if at all. If insurance is not an issue, I will usually choose Zepbound over Wegovy due to its better efficacy (21% loss in studies vs 15%) and better tolerability. However, if patients are paying ...