Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
When and how do you do testing for disaccharidases on GI biopsies?
You can send two biopsies from the 3rd portion of the duodenum for enzyme assays, but it might be easier just to do simple disaccharide absorption tests.
Do you prescribe respiratory muscle training (RMT) devices to patients with dysphagia?
We encounter dysphagia frequently in our patients with Parkinson's disease and other movement disorders. If there are any concerns about swallowing or aspiration, my first step is to refer to Speech Therapy for evaluation, and I defer to their expertise for specific treatments from there. That said,...
What factors make you consider an EUS before embarking on an ERCP for concern for type 1 Sphincter of Oddi dysfunction, (appropriate biliary symptoms, dilatation of ducts with no stones on MRCP, and liver labs suggestive of cholestasis)?
When clinical presentation is not typical for SOD and imaging raises the question of an anatomical/structural cause, or history of idiopathic recurrent pancreatitis, a diagnostic EUS may be helpful in this context. If the clinical presentation with LFTs and imaging meets criteria for type 1 SOD, EUS...
When and how should we use biomarkers (i.e., CRP, stool calprotectin, mAb levels) to guide or optimize medical management of Crohn’s disease or ulcerative colitis?
The principal clinical applications of biomarkers in IBD are as follows: Assessment of severity and prognosis during a flareup. Monitoring the efficacy of treatment. Determining the probability of postoperative recurrence of Crohn’s disease (i.e., the high negative predictive value of FPC for anasto...
In a patient with well-controlled ulcerative colitis on tofacitinib for several years, would you consider switching to upadacitinib for a more favorable side effect profile?
If it aint broke, dont fix it! No difference in AE profiles between tofa and upa.
Is there a role for use of JAK inhibitors instead of corticosteroids to induce clinical remission in those with severe ulcerative colitis?
Tofacitinib and upadacitinib are specifically approved for the treatment of moderately to severely active ulcerative colitis (UC), and both had steroid-sparing endpoints in their clinical trial programs. However, so do many of our newer therapies for UC. Both agents have demonstrated efficacy within...
How would you approach the evaluation of a patient with decompensated cirrhosis, suspect to be due to alcohol, who is not a liver transplant candidate with iron studies showing elevated saturation and ferritin over 1000?
The finding of elevated iron saturation (I suspect means above 55%) and high ferritin raises the diagnosis of true iron overload. Certainly, a Ferritin level above 1000, when the patient is not actively drinking, is consistent with cirrhosis. So, I would start phlebotomies if the Hgb >11-12 g/dL all...
In patients with suspected disorders of gut-brain interaction, at what point do you consider evaluating for carbohydrate malabsorption syndromes, and which test do you get?
My approach is based in part on the North American Consensus on breath testing. This is affirmed by other international consensus statements as well. It is important to first rule out microbial overgrowth with a lactulose breath test before doing carbohydrate malabsorption breath testing. If microbi...
How do you approach an otherwise healthy patient with an incidental 1 mm GIST involving the serosal surface in terms of staging workup, EGD, and surveillance?
These incidental "micro-GISTs" are not likely to become a clinical problem. Interestingly, you describe a "serosal" lesion which would not get picked up on endoscopy anyway, but not unreasonable to check again in a year with a CT AP and EGD. I don't think we have any evidence to support continued lo...
Do you have a standard approach to using POCUS to evaluate acute abdominal pain?
I don't have a standard framework for evaluating acute abdominal pain because my approach as a hospitalist depends very much on the history and available data. This is usually very different from the ED context, though we not infrequently have patients develop acute abdominal pain during hospitaliza...