Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
How long do you typically treat patients with phentermine for weight loss and what clinical markers do you follow?
Phentermine has been available since 1959 and remains an affordable and effective medication option added to a full lifestyle-based weight management plan. In people who are generally healthy and without contraindications to the medication, I have had patients used in at least intermittently for sev...
In a young patient who was vaccinated against chickenpox as a child (no previous varicella infection), should the patient receive a shingles vaccine prior to starting Rinvoq?
Yes. The vaccines are different and current vaccine is to prevent zoster for patients who have been previously exposed to varicella or vaccinated for varicella.
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 is your approach to managing constipation in patients with chronic kidney disease?
I would avoid magnesium- and phosphate-containing laxatives in patients with advanced CKD. Polyethylene glycol, lactulose, senna, or bisacodyl can be safely used in these patients. Linaclotide and lubiprostone can be used in refractory constipation.
Do you instruct patients with non-EoE EGID treated with budesonide to modify the capsules based on the specific location of the GI tract that is being targeted?
We suggest different approaches depending on the diagnosis. For eosinophilic gastritis, we recommend liquid budesonide (respules), unmixed or mixed with only a small amount of Splenda for taste. For eosinophilic duodenitis, we recommend that enteric budesonide (Entocort) be crushed and swallowed. If...
When would you consider prolonged NPO prior to EGD, TEE, etc. in a patient with a history of severe gastroparesis?
12 hours.
Is there a particular prokinetic agent that you recommend if a patient has failed both PPI and TCA in the treatment of suspected functional dyspepsia?
In general, the evidence to support the use of prokinetics in functional dyspepsia (FD) is not strong. The rationale for using a prokinetic agent for FD is to improve gastric emptying time in the subset (about ¼) of patients who delayed gastric emptying which is usually mild. The three prokinetic ag...
What is your general approach to treating bleeding gastric masses with palliative RT?
We once had a patient with stage IV NHL who had transfusion-dependent bleeding from a pesky gastric mass that was chemo-resistant. It turned into a fatal complication, so it was presented as an educational case at ASTRO. We gave 4 Gy x 1 which stopped the bleeding within 24h, and switched to 3 Gy x ...
How do you decide between systemic vs. arterially directed therapies in the first line setting for unresectable HCC?
In IMbrave150, 63% of patients treated with atezolizumab/bevacizumab had extrahepatic spread of disease, and my recommendation for patients with extrahepatic involvement is for first line systemic therapy. For patients with unresectable disease without extrahepatic spread, we take a multi-disciplina...
What is your approach to isolated alkaline phosphatase without other laboratory abnormalities?
Assuming none of the other LFTs are abnormal, I would get a GGT. If GGT is elevated --> likely a hepatobiliary issue. Would consider age, medical history, and risk factors. If persistently elevated, could consider RUQ US + MRCP. Conditions like PSC or PBC are frequently discovered due to asymptomati...