Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
What is your experience with transesophageal lung mass biopsies?
Thoracic lesions requiring FNA in the mediastinum are often best approached with EUS–FNA, as the sedation and airway management are less complex than the EBUS, and the needle does not need to break through cartilage rings to access the lesion. On the other hand, a lung mass would require the needle ...
How do you approach a patient on anti-TNF with positive Quantiferon (previously negative) with negative chest x-ray and no symptoms?
Prior to routine screening for latent TB for patients receiving or about to receive TNF inhibitor therapy, there were reports of miliary TB developing after initiation of TNF inhibitors. Therefore, one cannot say that a negative chest x-ray and no symptoms means the patient is not at risk for develo...
For patients with eosinophilic esophagitis in remission on stable maintenance therapy, at what intervals should you consider repeat endoscopic evaluation?
This is a good question, as there is no standard surveillance interval. In our practice, for stable patients, we recommend routine clinical follow-up every year to assess symptoms and medication adherence. For patients thought to be in remission and on stable therapy, we consider repeat endoscopy ev...
In light of recent measles outbreaks in the US, would you recommend an MMR booster for immunocompetent patients born before 1957?
I would not recommend a measles vaccine for a person born before 1957. This year has been chosen because people before born before 1957 have a very very high likelihood of having had measles because virtually all children got this highly contagious disease. On the other hand, there is no harm to get...
Is there benefit to aggressively treating hemochromatosis in a patient who has already progressed to cirrhosis at the time of diagnosis?
The short answer is yes, there is a benefit to treating iron overload in a patient with hereditary hemochromatosis (HH) with cirrhosis. HH involves at least five mutations, most commonly in the HFE gene (common variants include C282Y and H63D), leading to hyperabsorption of iron and progressive accu...
What is your approach to work up and management of a patient with advanced HIV and poor adherence to therapy presenting with dysphagia and fever?
Having a sense of a recent CD4 value would help. After a thorough H&P to assess for localizing symptoms beyond the dysphagia and no available CD4 data, I would approach this patient as someone with a CD4 count of <100 and possibly <50. It is highly likely that they have candida esophagitis, for whic...
How do you approach surveillance of gastric hyperplastic polyps of various sizes?
Gastric hyperplastic polyps are the second most common gastric polyps, behind fundic gland polyps. Unlike hyperplastic polyps in the colon, gastric hyperplastic polyps can be associated with chronic inflammation, notably Helicobacter pylori gastritis or autoimmune gastritis, for example. The neoplas...
What role do you feel there is for antibiotics in the management of severe perianal Crohn's disease?
Without access to biologics you still should have access to a thiopurine. That has some efficacy and was all we had prior to biologics along with chronic antibiotics.
Do you routinely recommend diagnostic endoscopy for patients with persistent enterococcus bacteremia despite receiving adequate antimicrobial therapy and no clear nidus?
It depends. Did you do an echocardiogram to rule out endocarditis? Urine cultures were negative? Gallbladder ultrasound was negative? CT of the abdomen and pelvis with contrast was negative?Any other symptomatology that accompanied the recurrent episodes of enterococcus bacteremia that could help us...
When noninvasive tests are discordant (e.g., low FIB-4 but elevated VCTE and ELF), what is your decision algorithm for initiating a GLP-1 receptor agonist for MASH, and what specific discordance threshold makes you revert to biopsy?
I rely more on vibration-controlled transient elastography (VCTE) than the Fibrosis-4 (FIB-4) index or the Enhanced Liver Fibrosis (ELF) score. I use FIB-4 as more of a screening tool to inform next steps rather than a definitive diagnostic assessment of fibrosis. If I am wary of my VCTE results, I ...