Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
What is the role of liver transplant in NET?
Identifying the role of liver transplant (txp) in NET patients with all the other therapy options available is challenging. I will admit that there have been several years since I last was involved in the care of a patient that actually ended up having a liver txp. That said, I think certain patient...
Is there a serum ammonium level for which you recommend initiation of dialysis in a patient with hepatic encephalopathy?
Because there is a very poor correlation between ammonia levels and hepatic encephalopathy, I do not make recommendations based on ammonia levels. My approach is to treat each case individually in consultation with our hepatology colleagues. If a patient has encephalopathy and is not responding to m...
With OpenBiome no longer in operation, what is your current approach for obtaining FMT for inpatients with acute severe/fulminant C. difficile infection unresponsive to antibiotics?
Consider Rebyota by enema or flex sig, similar to what you had done with standard FMT.
When managing patients with suspected MASLD, what specific criteria or findings would prompt you to refer them to hepatology?
In patients with suspected MASLD, I consider referral to hepatology when there is evidence of fibrosis by elastography or if I don't see improvements in related parameters with weight loss and/or medical therapies (GLP1-related meds, SGLT2i, TZDs).
When do you consider scheduled antiemetics in hospitalized patients experiencing severe nausea?
The biggest problem I see is antiemetics given PRN when a patient has consistent nausea. The goal is to get above the nausea so that the patient begins to feel better. This is similar to how one treats pain. Thus, if a patient is taking an antiemetic more than once a day and has consistent nausea, I...
Can patients "age out" of screening colonoscopies if, on their last colonoscopy prior to turning 76, they had tubular adenomas?
How long ago was the last colonoscopy? How many adenomas? How old is the patient now? State of health and expected longevity? What does the patient want? Frankly, at this point, I think I’d probably be content with an annual FIT.
In a young patient who was vaccinated to chickenpox as a child (no previous varicella infection) should the patient receive a shingles vaccine prior to starting Rinvoq?
Yes. The vaccines are different and current vaccine is to prevent zoster for patients who have been previously exposed to varicella or vaccinated for varicella.
What are your vaccine recommendations while patients are on biologics?
Live vaccines are best completed at least a month before initiation of biologics when these are appropriate (e.g., MMR, chickenpox, yellow fever). The data on non-live vaccines is limited. I personally think that some degree of protection is better than none. I will not interrupt biological therapy ...
Should GLP-1 agonists be held during chemotherapy?
I think there are several aspects to this question. First, is there evidence that as a class GLP-1 RAs increase the risk of cancer or worsen prognosis during cancer? I could find nothing to raise concerns about outcomes. One recent report even showed a decreased risk of some cancers with GLP-1 RA co...
How do you approach surveillance of gastric hyperplastic polyps of various sizes?
Gastric hyperplastic polyps are the second most common gastric polyps, behind fundic gland polyps. Unlike hyperplastic polyps in the colon, gastric hyperplastic polyps can be associated with chronic inflammation, notably Helicobacter pylori gastritis or autoimmune gastritis, for example. The neoplas...