Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
In patients with sarcoidosis and persistently elevated liver function tests, when do you consider initiating ursodeoxycholic acid (UDCA)?
In patients with systemic sarcoidosis with predominantly elevated alkaline phosphatase, I would be suspicious for liver involvement of their sarcoidosis. If treatment of the systemic sarcoidosis with immunosuppression (typically initiated by Pulmonology or Rheumatology) are ineffective for improving...
In patients with MASLD, would you consider management with off-label metformin, pioglitazone (despite weight gain risk), GLP-1 RA, or simply intensify lifestyle and monitor?
In 2025, we should be assessing if patients are developing F2-F3 fibrosis especially with the use of non-invasive assessments (FIB-4 score, transient elastography, or MRI elastography), and then offering either Semaglutide or Resmetirom for these individuals w/ F2-F3, which are the only FDA approved...
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...
How soon after an acute upper GI bleed do you restart therapeutic anticoagulation in a patient with atrial fibrillation and a high thromboembolic risk (CHA₂DS₂-VASc ≥4)?
In real-world inpatient practice: ~72 hours after endoscopic control for high-stroke-risk AF with stable hemoglobin and no rebleeding. Extending hold to 5–7 days if the lesion is high risk or the bleed was severe.
If an ulcerative colitis patient has a 90 percent response to a biologic or small molecule after over 12 months, would you consider switching medication to a different class in hopes of getting a complete response, versus trying adjunctive therapy?
I am not sure what you mean by “90%” response. Is that clinical, laboratory, or endoscopic? Perfection is the enemy of good, so you'd better have a compelling reason to make a patient add another therapy.
Would you use upfront atezo/bev in a patient with HCC and untreated hepatitis?
Yes. I would not have concerns. For HBV, I would start treatment before or simultaneously. Studies have varied by protocol about the HBV viral load being under 500 or 100 but it is not clear this matters. There have not been flairs reported. In regards to HCV, again, not an issue for me.
In a patient with recurrent SBOs due to Crohn’s ileitis despite treatment with infliximab, do you consider switching to a different biologic versus resection?
The short answer is NO. Recurrent obstructions in Crohn’s disease are a mechanical problem, and they require a mechanical solution. Continuing medical therapy is a waste of time.
What vitamins and minerals do you check yearly for patients post gastric bypass surgery?
Following Roux-en-Y gastric bypass it is essential to monitor micronutrients, vitamins, and minerals because malabsorption and long-term complications may occur with improper care. Based on ASMBS 2016 Nutrition Guidelines, AACE/TOS/ASMBS 2019 updates, and Endocrine Society recommendations, here are ...
In a patient with chronic intestinal pseudo-obstruction who develops refractory postoperative ileus, what is your pharmacologic escalation strategy and when do you move beyond medications to endoscopic or procedural interventions?
I would start with alvimopan; second line, methylnaltraxone.