Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
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...
In a young patient who was vaccinated to 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.
Should GLP-1 agonists be held during chemotherapy?
I think there are several aspects to this question. First, is there evidence that as a class GLP-1 RAs increase the risk of cancer or worsen prognosis during cancer? I could find nothing to raise concerns about outcomes. One recent report even showed a decreased risk of some cancers with GLP-1 RA co...
What is you approach to C. difficile treatment in patients admitted for acute severe ulcerative colitis (ASUC) with a positive GDH and PCR with a negative EIA for toxins?
GDH is an excellent screening test, but not specific for C. diff. The PCR is for the toxin gene, but does not necessarily indicate that there is toxin production or clinical C. diff. So this combination does not likely represent active C. diff. However, the toxin assay has about a 15% false negative...
Is there a role for checking calprotectin, or other markers of inflammation, in decision making or monitoring in patients undergoing abdominopelvic radiotherapy with history of IBD?
The fecal calprotectin is neither sensitive nor specific enough to determine the protocol for radiotherapy. In fact, the very disease requiring the radiation may contribute to the results! If you need to know the condition of the rectosigmoid, a flexible sigmoidoscopy should be your best bet.
Do you switch to an alternative agent for C difficile colitis for a patient with suspected infection and positive testing who continues to have >3 watery bowel movements daily despite multiple days of oral vancomycin treatment?
The question about switching to another agent for Clostridioides difficile (Cdif) colitis in a patient who tests positive for Cdif but continues to have diarrhea despite multiple days of oral vancomycin treatment does not include any information regarding the clinical status of the patient, the pres...
What is your approach to the management of chronic GI bleeding from AVMs in an elderly patient on DOAC for atrial fibrillation?
I would definitely strongly consider the left atrial appendage occlusion device in these patients. While usually these devices (such as Watchman) do require anticoagulation for about 45 days until the device has an endothelial layer form on it (we usually confirm with a CT scan or TEE), there are so...
If a young patient with biopsy proven EOE is doing well on bid PPI, when would you consider switching to Dupixent in order to precent long term complications such as strictures?
If the patient is in proven histologic remission on PPI and the symptoms are well-controlled, then the patient has PPI-responsive EoE and can stay on PPI as maintenance therapy. There is no indication for switching to Dupixent in this scenario except for patient preference. There is no current evide...
Would you avoid risankizumab in a patient with stricturing Crohn’s complicated by granulomatous bronchiolitis with stenosis who had to stop ustekinumab due to hemoptysis?
Unless there had been a rapid and dramatic beneficial response of the Crohn’s disease to ustekinumab, I would have little appetite for trying another IL-blocker. A different mechanism, like JAK, might be worth trying, but the serious pulmonary complication probably warrants steroid therapy. One coul...
How do you approach the treatment of reflux hypersensitivity in patients on PPI therapy?
Reflux hypersensitivity is defined by typical reflux symptoms with normal endoscopy and normal esophageal acid exposure, but positive symptom association with physiologic reflux events on pH testing. Because acid exposure is normal, escalating PPI therapy is usually not beneficial, and treatment ins...