Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
How do you manage a patient with dysphagia whose EGD shows mild esophageal rings and furrows, but histology was negative for interepithelial eosinophils?
That is a great question. The question stem gives the impression that the endoscopic appearance is suggestive of eosinophilic esophagitis. A few things to consider: First, I would make sure that the procedure was done off any treatment, especially PPI therapy. Many patients come for endoscopy alread...
Has the recent trial by regarding long-term outcomes changed your default salvage therapy after failed Heller myotomy in a patient with recurrent achalasia?
In our practice, we certainly do discuss both POEM and pneumatic dilation for patients with recurrent symptoms who have previously had a Heller myotomy. We feel that POEM is a very reasonable and appropriate next step in these patients, but ultimately, it comes down to a discussion with the patient ...
In patients with iron deficiency due to history of gastric bypass or IBD, would you consider oral iron therapy if the iron deficiency anemia is mild?
Oral iron can often be effective in iron deficiency, as long as absorption is intact. If you are concerned about absorption, performing an oral iron challenge can be useful in allowing you to avoid long trials of oral iron that will be ineffective. Simply check an iron panel at baseline, then admini...
How do you manage a patient in his 90s with achalasia type 1 and an Eckardt Symptom Score of >6 who is not a Peroral Endoscopic Myotomy (POEM) candidate?
I do not think POEM is out of the question, but if he is a poor surgical candidate, then I would trial a course of Botox injection into the LES. Hope that helps.
Which patients, if any, do you revert back to ultrasound screening for HCC after prior diagnosis/definitive treatment of HCC?
I don't revert back to U/S for these patients ever. It's not dissimilar from colorectal cancer screening - once you have colon cancer, it's not appropriate to use iFOBT or stool DNA screening anymore - it's lifelong colonoscopy screening. Likewise, for HCC, I continue to use AFP plus cross-sectional...
How do you approach the treatment of microscopic colitis?
If there is a temporal association between starting a drug like NSAIDs, PPI, SSRI, statin in the onset of diarrhea deny would stop the medication before beginning pharmacological therapy for microscopic colitis. If there is no potential drug trigger, and I stratify my treatment based on severity of ...
How do you approach managing depression symptoms in patients who have had repeated high risk of bleeding?
Overall, evidence suggests that while SSRIs do increase the risk of bleeding. The absolute risk of a bleeding event remains low and is usually not serious. A 2017 meta-analysis by Laporte et al., suggested that overall bleeding risk is increased by at least 36% while other meta-analyses suggest that...
With the latest hepatitis B guidelines and recent phase 3 trial of Bepirovirsen mentioning the utility of quantifying HBsAg levels, how have you incorporated HBsAg in your practice?
Since the first New England journal publication on Bepi (Yuen et al., PMID 36346079), which demonstrated functional cure in patients with less than 1,000 international units of surface antigen, we’ve been quantifying surface antigen in all of our hepatitis B patients. Almost all the large commercial...
After endoscopic control of variceal hemorrhage, what minimum safety bundle (timing, tube type/size, monitoring, and contraindications) do you require to place a small-bore nasoenteric tube within 24 hours for nutrition and hepatic encephalopathy therapy?
I usually wait at least 48 to 72 hours before placing a Dobhoff or Keofeed small-bore nasoenteric tube. This allows sufficient time for bands to create their local ulcers and then fall off, minimizing the risk of rehemorrhage.
What is your approach to terminal ileal structure in the setting of a new diagnosis of Crohn’s disease on index colonoscopy?
If there have been episodes of symptomatic obstruction or if there is proximal dilation on imaging, I would forgo any medical therapy and move straight to resection.