Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
How would you approach the consideration of continuing or ceasing colonoscopy for colon cancer screening in a relatively fit man in his 80s without a history of polyps on prior colonoscopies?
For someone in his 80s who has received good screening and never had polyps, continuing colonoscopy brings little benefit. The risks and difficulties from the procedure become greater with age, so, for most older adults, stopping routine screening is usually the better option for geriatric care. Whe...
How would you approach the management of asymptomatic ALT and GGT elevation in an older adult patient with depression with psychosis and without history of hepatitis who recently had dose of quetiapine increased and new initiation of SNRI?
The answer when you suspect drug-induced liver injury depends on the X elevation above normal of ALT and bilirubin. In addition, exclusion of other coexistent factors, i.e., alcohol use, metabolic risks, or other medications. From liver tox, quetiapine may elevate liver tests in 30% of patients. Bel...
How do you approach the treatment of UC with PSC and how do you position oral vancomycin against biologic therapies?
A number of case reports have suggested that oral vancomycin improved the course of PSC, but more rigorous clinical trials have failed to confirm the benefits. [Deneau et al., PMID 32946600. Assis & Bowlus., PMID 37084929]The treatment of neither UC nor PSC seems to affect the other condition. That ...
How do you remove and code for the following polyps?
I would inject and remove with a hot snare. It also depends on the location of the polyp. If the polyp is in the cecum, I would use a cold snare. I would code this as EMR. I would inject and remove this one also in one piece if possible. I would code this as EMR.
In patients on long-term proton pump inhibitors for GERD with stable symptoms, do you routinely attempt discontinuation or continue indefinitely given relapse risk?
This is a good question, as we see many patients who were placed on PPIs and continued indefinitely for GERD. As this question implies, this may not be necessary, and long-term PPI use comes with risks that include C. diff. There are additional studies that suggest fractures, CKD, and nutrient defic...
How do you approach dosing beta blockers for variceal prophylaxis when the standard dose doesn’t achieve the target heart rate?"
The question is obsolete, actually, as the preferred beta-blocker for variceal prophylaxis is now carvedilol per AASLD guidelines as of 2024. Carvedilol is preferred given more optimal lowering of portal pressure as well as data supporting reduced risk of decompensation. Carvedilol is not titrated t...
What is your approach to secondary prophylaxis and post-discharge planning after an acute esophageal variceal bleed in a patient with ongoing alcohol use disorder and major social barriers (uninsured, homeless)?
Obviously, these questions are moot in the setting of an acute variceal bleeding when a life-saving TIPS becomes necessary; we then deal with these issues afterwards. We frankly go as far as we can with medical/endoscopic therapy before considering TIPS as an option for repeated bleeding episodes, w...
In a patient with dysphagia and manometry showing diffuse esophageal spasm or ineffective motility plus positive pH study, how long should GERD be treated before reconsidering the diagnosis of achalasia, and what additional testing should be pursued?
I agree with the previous answer. Ultimately, if there is still concern for achalasia despite esophageal manometry, one can obtain a timed-barium swallow to assess esophageal emptying, or EndoFLIP to evaluate the LES/EGJ distensibility.
What is your approach to work up and management of a patient with advanced HIV and poor adherence to therapy presenting with dysphagia and fever?
I would first do an HPI (is the dysphagia for both liquids and solids?), then a quick physical exam, with a full set of vital signs. In terms of basic blood work, I would get a CBC and BMP, liver function tests, a set of blood cultures, a chest x-ray, along with a viral load and CD4 T cell count, wh...
When do you consider de-escalating therapy such as dupilumab in eosinophilic esophagitis?
It is first important to recognize that EoE is a chronic condition. In a patient whose EoE is successfully being treated (whether it be with PPI therapy, swallowed steroids, food elimination, or dupilumab), the disease will invariably become active again over time if therapy is stopped. This is why ...