Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
What is your strategy in the management of patients with autoimmune hepatitis who failed azathioprine therapy and what parameters do you monitor with what frequency?
Great question. Around 10% of autoimmune hepatitis cases don't respond to azathioprine (AZA) and 15% may have an incomplete response to AZA. These patients require second-line therapy. Before initiating second-line therapy, it's important to exclude non-adherence. Mycophenolate Mofetil (MMF) is the ...
How do you balance the need for diuretics from a volume perspective (Ex: ascites, edema) in decompensated cirrhotic patients and progressive renal dysfunction?
There is no discrete answer to this question. Much depends on the overall goal of care. For a transplant candidate, higher creatinine may be needed for transplant access and be tolerated, but risk need for post-transplant RRT. If goals are palliative, symptom control supersedes renal function.
In patients with F2/F3 fibrosis, would you start Resmetirom if they had normal liver enzymes?
Yes, it would be reasonable, especially if you can prove that they still have significant steatosis (such as a CAP of >300 db/m) or active MASH on liver biopsy, as Resmetirom works by directly removing fat from the liver. The lack of liver enzyme elevation is not a reliable sign to rule out steatohe...
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 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...
For remote liver transplant recipients back under the care of a community gastroenterologist (or PCP), what should be the approach to new liver enzyme elevations?
Elevated liver enzymes in post-transplant patients who live far from their transplant center are a common challenging issue. Many factors will influence your recommendation to the local physician: height of enzyme elevation, cholestatic, hepatitic, or mixed profile, and associated symptoms (pain, fe...
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.
What clinical features would raise your suspicion for IgG-4 related disease?
IgG4-related disease can affect multiple organs, leading to varied presentations. In the abdomen, patients can have symptoms secondary to pancreatitis and or biliary obstruction. In the liver, patients can present with a PSC-like picture (jaundice, cholangitis, ductal strictures/dilatation) that, un...
Would you ever consider switching a patient with an LVAD from warfarin to Eliquis, such as in the setting of recurrent GI bleeds?
In general, warfarin remains the agent of choice in VAD patients. However, in patients with INR non-adherence or recurrent GI bleeds, it is an option. In this situation, ensure that GI bleeding is stopped and start 2-3 days after warfarin is stopped. Monitoring with anti-factor Xa monitoring can be ...
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...