Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
Do you routinely check Infliximab levels on day 3 with patients admitted with acute severe ulcerative colitis?
Conceptually, while this is an important concept, from a practical standpoint, most hospitals do not have a point-of-care IFX assay that can provide levels right away. Most IFX levels in the real world take around a week to come back, which makes that not impactful from a clinical standpoint in acut...
Is there evidence that certain PPIs provide superior clinical efficacy compared to others in real-world practice?
While there are some differences between PPIs in terms of metabolism, bioavailability, and duration of acid suppression, generally speaking, in clinical practice, the efficacy of different PPIs is comparable. With that said, some differences include dexlansoprazole's dual-release nature which genera...
What is your preferred analgesic in patients with small bowel obstruction or ileus?
I typically use IV Tylenol ATC if fully obstructed, and IV Toradol if no other contraindications to NSAIDs (and they often are quite prerenal or losing a lot of fluid from an NG tube, so I often don't feel comfortable with more than a couple doses, and if I think they are going to the OR, I do not u...
How do you approach HCC screening in patients with advanced fibrosis e.g., F3 on FibroScan?
We should first understand the underlying principles that defined the various cut-offs that resulted in this recommendation (eg, cost-effectiveness threshold for HCC screening, cut-offs for advanced fibrosis) and then go from there. Among patients with cirrhosis, the cost-effectiveness threshold wa...
Do you avoid peritoneal dialysis in cirrhotic patients with ascites?
There are two major concerns regarding the performance of PD in patients with ascites: the potential for fluid leakage at the site of the newly placed catheter and the perceived increased potential for peritonitis. In my experience, neither of these is a compelling reason to shy away from PD in a pa...
What techniques do you find most effective for visualization of rectal disease with intestinal ultrasound?
I am not sure that this is the correct use of "intestinal ultrasound". There is the transabdominal ultrasound technique that is taught to gastroenterologists who can use it at point of care for their UC and CD patients to assess the small bowel and the colon. If you want to specifically look at the ...
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...
What are your go-to medical management options for high ileostomy output in patients with >100 cm of remaining small bowel?
First of all, you have to make sure that the patient's liquid intake is not composed of free water but an electrolyte solution at least 50% of the time. Metamucil at night Nana flakes in a milkshake at night Medication stepwise: Maximize loperamide Add diphenoxylate Add a PPI to reduce acid secre...
In patients with EGJOO on esophageal manometry, how do you approach subsequent testing for further evaluation?
In order to make a clinically relevant and conclusive diagnosis of EGJOO, patients must not only have manometric findings of EGJOO but also clinically important/related symptoms and at least one additional test which shows evidence of obstruction at the EGJ. This additional testing is with either a ...
Where do SIBO testing and/or empiric antibiotics fit into the management of patients with bloating, abdominal pain, diarrhea, constipation, or distention?
There are now consensus papers on breath testing from North America, Europe, Asia (and Australia), Brazil, and, most recently, Argentina. All state that SIBO testing is important in the management of these functional symptoms. We have shown that methane is a cause of constipation, and Hydrogen on br...