Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
In hospitalized patients treated for presumed overt hepatic encephalopathy who show no meaningful improvement after 48–72 hours of adequate therapy and precipitant management, what is your highest- yield next diagnostic step and what clinical features drive that prioritization?
At this point in the clinical care pathway, I would repeat an infectious workup (blood, urine, diagnostic paracentesis; occult infections are common in our cirrhotic patients) and perform a high-quality multiphasic cross-sectional imaging test to look for portosystemic shunting that could cause refr...
In patients treated with infliximab, do rates of immunogenicity vary based on underlying disease (RA, IBD, sarcoidosis, etc) and/or baseline disease activity?
Yes, rates of infliximab immunogenicity appear to vary based on underlying disease, with evidence showing higher rates for RA than IBD and spondyloarthritis, and tend to increase with higher baseline disease activity. Most patients tend to develop anti-drug antibodies within the first year, but this...
Do you routinely give prophylactic antibiotics prior to ERCP for biliary obstruction in light of recent studies suggesting a reduction of periprocedural infection?
I did not use to give antibiotics routinely prior to ERCP, and it seemed post-ERCP antibiotics were given at the discretion of the advanced endoscopist, but the results of this meta-analysis will likely change my practice so that I'll give all patients a dose of Ceftriaxone prior to the procedure to...
What is your treatment approach to a patient with budesonide refractory microscopic colitis and multiple sclerosis?
First job is to be sure the colitis is not attributable to any medication, particularly ocrelizumab. Meanwhile, have you given an adequate trial of bismuth?
When can we consider deferring an insulin drip in patients with hypertriglyceridemia-induced pancreatitis?
Serum triglyceride levels >500 mg/dL (5.6 mmol/L) are required for hypertriglyceridemia to be considered the underlying etiology of acute pancreatitis (UpToDate).For patients with severe hypertriglyceridemic pancreatitis, such as those serum triglyceride levels >1000 mg/dL plus lipase >3 times the u...
What interventions do you find helpful for the initial management of functional GI disorders in primary care?
TCAs seem to help modulate pain, particularly at low doses.
Do you prefer formal testing to establish a diagnosis of SIBO/IMO over empiric treatment?
Great practical question. I prefer formal testing for several reasons: Even though postprandial bloating and distention along with change in bowel habits are the hallmarks of SIBO/IMO, they are non-specific and can be caused by myriad of other organic causes. A normal breath test would direct the a...
How do you decide when to use acid-suppressive medications for GI prophylaxis when patients are on prolonged corticosteroid therapy?
We only use acid-suppressive medications for GI prophylaxis in patients treated with corticosteroids when they have additional risk factors for upper GI bleeding. Risk factors include concomitant NSAID or antiplatelet therapy, history of GI bleeding or peptic ulcer, age over 60 years, prednisone dos...
In lean MASLD with sarcopenia or visceral adiposity despite normal BMI, how do you prioritize resistance training/nutrition versus pharmacologic cardiometabolic prevention, and what metrics do you track to decide if the plan is working?
I don't think this is a dichotomous choice, as resistance training and nutrition are complementary to pharmacologic cardiometabolic prevention. From a pharmacologic perspective, I would be cautious with incretin-based therapies as these may worsen sarcopenia, especially in an already lean (i.e., nor...
Can fatty liver disease present with elevations in alkaline phosphatase without other liver enzyme elevations (AST and ALT)?
It is very atypical but can occur. Patients usually have elevations in aminotransferases (usually ALT higher than AST) and there can be very mild concurrent elevations in alkaline phosphatase. An isolated alkaline phosphatase elevation should however prompt a more extensive serological work up as we...