Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
How do you decide which patients should pursue add-on bepirovirsen rather than continue indefinite nucleos(t)ide analogue monotherapy for noncirrhotic chronic HBV?
HBsAg quantitation to determine if they meet criteria Frank discussion that only 1 in 5 patients succeed and that the 6-month weekly injections do have a relatively high rate of significant adverse hematological and renal complications requiring close laboratory monitoring. So far, most patients h...
Where do SIBO testing and/or empiric antibiotics fit into the management of patients with bloating, abdominal pain, diarrhea, constipation, or distention?
There are now consensus papers on breath testing from North America, Europe, Asia (and Australia), Brazil, and, most recently, Argentina. All state that SIBO testing is important in the management of these functional symptoms. We have shown that methane is a cause of constipation, and Hydrogen on th...
What patient characteristics guide the selection of a step-up versus a step-down elimination diet strategy in the management of eosinophilic esophagitis?
It is a shared decision making between the Physician and the patient. The step-up approach requires fewer endoscopies and may be better tolerated and accepted by the patient. But again a detailed discussion with the patient is needed for any kind of diet strategy to work.
How would you manage an asymptomatic patient after VCE showing small bowel Crohn's who passes the patency capsule but has retained the video capsule in the distal ileum with minimal surrounding inflammation?
A capsule can take up to 10 days to pass in a normal situation. If you have radiographic evidence of a retained capsule and the patient is on prednisone, it might take another 2 weeks or so to get the inflammation down. Remember that the capsule should continue to get crushed and really should pass ...
Which other GLP-1 R agonist, if any, would you consider re-trialing in patients who had severe gastrointestinal side effects with Ozempic?
I am curious if you mean someone who has not tolerated the lowest dose of Ozempic, or higher doses. I have had patients who have not tolerated semaglutide but who can tolerate tirzepatide (or dulaglutide or even liraglutide if a daily injection is OK). I have also used "click counting," which is uni...
Is there a serum ammonium level for which you recommend initiation of dialysis in a patient with hepatic encephalopathy?
Because there is a very poor correlation between ammonia levels and hepatic encephalopathy, I do not make recommendations based on ammonia levels. My approach is to treat each case individually in consultation with our hepatology colleagues. If a patient has encephalopathy and is not responding to m...
What is your approach to secondary prophylaxis and post-discharge planning after an acute esophageal variceal bleed in a patient with ongoing alcohol use disorder and major social barriers (uninsured, homeless)?
Obviously, these questions are moot in the setting of an acute variceal bleeding when a life-saving TIPS becomes necessary; we then deal with these issues afterwards. We frankly go as far as we can with medical/endoscopic therapy before considering TIPS as an option for repeated bleeding episodes, w...
Do you routinely perform serologic testing for systemic sclerosis when absent contractility is identified on high-resolution manometry?
This is a good question. The first thing to consider is the LES pressure. If a patient has elevated LES relaxation pressure on high-resolution esophageal manometry, in combination with absent contractility, then this would be concerning for achalasia type 1 (especially when a patient also has delaye...
When would you consider use of EUS guided liver biopsy over percutaneous and/or transjugular?
If data (labs, imaging) are not entirely compelling for a primary parenchymal or biliary issue, then EUS liver biopsy can be an efficient approach in addition to ERCP (saving the need for separate biopsy in the event that ERCP is non diagnostic).
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...