Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
How do you adjust medications for patients with eosinophilic esophagitis who responded to budesonide or PPI, and when do you repeat EGD?
Repeat EGD after BID PPI is normal- do you decrease to once-a-day PPI? When to repeat EGD if ever? I try to decrease to once daily in the morning, but if so, I repeat an endoscopy 3 months later to make sure histologic remission is still maintained. After response to Budesonide, continue life-lo...
How would you approach diagnosis of a patient with recurrent episodes of abdominal pain, severe myalgias, low grade fevers and urticaria?
Without the mEFV variant, from a rheumatologist viewpoint, the differential includes IBD, a periodic fever syndrome such as FMF or FCAS, and MCAS. Therefore, I would consider that workup with genetic testing (anyone can send!), fecal calprotectin, and MCAS eval with A/I. I don't think of urticarial ...
What factors do you consider when a patient with acute severe ulcerative colitis flare responds to inpatient Infliximab, and you are deciding whether to switch to subcutaneous or continue IV maintenance dosing of Infliximab?
Patients admitted with acute severe ulcerative colitis typically have higher drug clearance related to significant fecal loss of infliximab through a highly inflamed colon, leading to low levels and often the need for dose escalation. There have been studies showing that infliximab levels in severe ...
Would you consider Resmetirom in a patient with metabolic risk factors and persistently elevated transaminases despite lifestyle changes, after a negative workup for other liver diseases, with noninvasive testing suggesting minimal fibrosis (F0–F1)?
Resmetirom is only approved for MASH with F2-3 fibrosis, so it will likely not get approved. If there is evidence of continued hepatic steatosis and no other competing etiologies, would continue current lifestyle recommendations and repeat fibroscan, ELF, or MRE in 1 year. If competing etiologies (e...
What is your treatment algorithm for solitary hepatocellular carcinoma, 3-5 cm, non-operative candidate but Child-Turcotte Pugh A/B?
This really boils down to two issues: CTP score and size of the lesion. For patients who are CTPA with a lesion <3 cm, RFA/MWA or SBRT are good options although there is some data from the University of Michigan (Wahl et al., JCO 2014) that lesions > 2 cm are better served with SBRT. For solitary le...
Do 5HT4 agonists such as Metoclopramide actually lead to improvement in symptoms for patients with diabetes related gastroparesis?
Yes, sometimes when the gastroparesis is frequent or the symptoms are tough, I do use Reglan to help. By the time they wind up in the hospital, they are really willing to have me use anything on them that might help. I explain to every patient the side effects of Reglan, including tartive dyskinesia...
What is your approach to liver transplantation candidacy in those with decompensated cirrhosis who have been treated for a solid-organ malignancy, such as oral SCC?
This is an important consideration as patients who receive a solid organ transplantation will be on significant immunosuppression, which can result in significant proliferation of an underlying malignancy and have worse treatment outcomes compared to non-immunosuppressed patients. Furthermore, patie...
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 the recommended surveillance approach for gastric intestinal metaplasia in patients without gastric cancer risk factors?
For U.S. patients with gastric intestinal metaplasia (GIM) without high-risk features, both the AGA and the ACG recommend testing for and eradication of Helicobacter pylori infection as the primary intervention for gastric cancer prevention, while routine surveillance endoscopy is not recommended in...
How would you approach the management of an incidentally detected subcentimeter nodule located just below/adjacent to the GE junction in a patient without Barrett’s, that is found to harbor high-grade dysplasia (HGD) on pathology following EMR?
I think this depends on the pathology and whether margins were clearly negative. If there is HGD on the margin, I think pt would need further resection, likely ESD, to ensure no dysplastic tissue remains. In addition, careful inspection of the esophagus and stomach under HD-WLI, as well as NBI or BL...