Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
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...
What factors push you toward upfront necrosectomy rather than step-up drainage in a patient with symptomatic walled-off necrosis after four weeks?
The indications for intervention on walled-off pancreatic necrosis are typically signs that the fluid collection has become overtly infected (causing abdominal sepsis), significant mass effect on adjacent organs, gastric outlet obstruction, or resultant abdominal pain and anorexia. If the patient is...
Would you begin Semaglutide in a morbidly obese patient with intermittent elevations in ALT (100s) and with significant hepatic steatosis but without significant fibrosis?
I would start her on a GLP-1 RA, particularly if the patient had DM/pre-diabetic state. This would be more to reduce weight and decrease insulin resistance. The more dominant causes of morbidity and mortality in those with metabolic syndrome are heart disease and diabetes. Liver disease is number th...
When do you pursue liver biopsy for assessment of DILI?
In the setting of an acute elevation of liver chemistry tests, DILI should always be considered in the differential diagnosis. If the serological workup for abnormal liver tests is unrevealing as well as abdominal imaging, expectant management should ensue with the discontinuation of any potential o...
What specific “stop rules” do you use during difficult native-papilla biliary cannulation (e.g., time, cannulation attempts, pancreatic duct wire passages/injections) to trigger an early change in strategy, such as precut or referral/escalation?
I would not say 'stop,' but, as you said, 'change' the strategy. After attempting for about 5 minutes and touching the papilla with the catheter you started with 4-5 times, even if the guidewire goes into the pancreatic duct once, I tend to use that as a double-wire technique and then place a pancre...
How do you explain the use of an AI scribe to patients the first time it is used in their care?
I use an AI scribe in my outpatient clinic, and around 90–95% of my patients agree to it. I obtain consent at the start of each visit and make it clear that it's completely optional—that they can say no at the start or change their mind at any point in the visit, with no impact on their care. I also...
How do you counsel a patient on returning to the care of their PCP when a workup for MCAS has been unrevealing, but the patient insists that they have a mast cell disorder because they respond to antihistamine therapy?
At the end of the day, the treatment approach is the same as with mast cell activation syndrome (MCAS). There are additional relevant codes that can be helpful for these patients including 'mast cell activation, unspecified', and 'other mast cell activation disorders'.
Which patients would benefit from referral to a center with pancreatic function tests such as a secretin stimulation test?
The short answer is none. Secretin-stimulated pancreatic function tests are often used to diagnose "early" chronic pancreatitis and exocrine pancreatic insufficiency. The problem is that the test has poor accuracy for either condition. This is a test of pancreatic ductal cell function only, which is...
How do you decide between immediate liver transplant referral versus a time-limited “recompensation observation” period in patients with alcohol-related cirrhosis who present with a first decompensation and achieve early, verified abstinence?
It can be difficult to differentiate the two, so one never errs on the side of evaluating the patient for a transplant and then getting to know them and their support system a bit better. The more data and time you have to make such a decision, the better it is. Often, the natural history of the dis...
How do you think the advent of COCA (COlorectal Cancer detection with AI), which leads to incidental CRC detection, will affect your clinical practice?
Good question. COCA is interesting but very preliminary, and it's not clear how the tech (or concept) is different from CT colonography. There are several steps to go through, including validation in larger cohorts and finally a clinical validation study. Then there will be questions of resources, w...