Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
Is there a role for nitazoxanide for treatment of norovirus gastroenteritis in immunocompromised patients?
There is no good-quality evidence supporting a role for nitazoxanide for treatment of norovirus gastroenteritis in immunocompromised patients. The efficacy of nitazoxanide in viral gastroenteritis is supported by a small manufacturer-sponsored randomized, double-blind trial in non-immunocompromised ...
In a patient with chronic intestinal pseudo-obstruction who develops refractory postoperative ileus, what is your pharmacologic escalation strategy and when do you move beyond medications to endoscopic or procedural interventions?
I would start with alvimopan; second line, methylnaltraxone.
Do you use lactulose in acute liver failure, particularly in patients on continuous renal replacement therapy (CRRT) for ammonia or toxin clearance?
Generally lactulose should be avoided in the situation given limited benefit as well a tendency for ileus in ALF and potential for lactulose to cause bowel distention.
How do you approach the diagnosis of hepatorenal syndrome in a patient with cirrhosis and AKI who has not responded to albumin resuscitation but has a recent nephrotoxic exposure that could explain the renal dysfunction?
If the nephrotoxic exposure (e.g., aminoglycoside) is known to cause ATN, then the findings of low urinary sodium/fractional excretion of sodium, a bland urinalysis, and no structural abnormalities on renal ultrasound should make one consider HRS as the etiology of the AKI. The findings of granular ...
Would you consider the use of prophylactic antibiotics in patients admitted with decompensated cirrhosis with AKI with Cr>1.2, with ascitic fluid protein <1.5 without SBP and/or hyponatremia/Bili >3?
Is this in generalized cases or cases of GIB? If GIB, yes, I would consider it. In just generalized cases, there is no real role for empiric antibiotics.
In young, non-cirrhotic HBV–HDV coinfection with minimal fibrosis on elastography, do you perform lifelong 6-month HCC surveillance based on HDV status alone, or do you modulate surveillance intensity based on fibrosis trajectory and treatment response?
There are two separate issues. The frequency of liver cancer stent with used to initiate. It is not dependent on the risk of cancer. It is related to the doubling times of cancer in the ability to detect cancer when they are small, which is why a six-month interval is always chosen. While the rest ...
What initial workup do you perform when there is a concern for porphyria?
This is a terrific question. But a broad question. Porphyria refers to a defect in heme biosynthesis leading to the accumulation of porphyrins and porphyrin precursors. We should remember that there are three general categories of porphyria based on clinical manifestations: acute hepatic porphyria (...
How do you determine whether to limit volume removal during therapeutic paracentesis in a patient without acute or chronic kidney disease?
Large volume paracentesis (LVP) can lead to complications such as post paracentesis circulatory dysfunction. In patients who have ongoing acute renal failure, patients with borderline low blood pressure, or in patients who have a history of hyponatremia, LVP should be limited to 5L.
How do you approach the use of fidaxomicin versus vancomycin for initial Clostridioides difficile infection in immunocompromised patients, considering the lower recurrence rates but higher cost of fidaxomicin?
Whether immunocompromised or not, fidaxomicin has been demonstrated to be superior to vancomycin – not in resolution of the acute infection but in reducing the risk or recurrence by approximately one-half. In one study of hospitalized patients published in 2015, it was reported that, when taking int...
How do you decide between anticoagulation or portal vein recanalization in a patient with portal vein thrombosis?
It depends on cirrhotic vs non-cirrhotic. For cirrhotic, best to reference the AASLD 2020 guidance here - Northup et al., PMID 33219529.For non-cirrhotic: important to determine the etiology as well as evaluate for a hypercoagulable state, including checking for JAK2 and CALR.If acute and non-occlus...