Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
How do you decide whether to initiate semaglutide for MASH when alcohol intake is near MASLD/MetALD boundary ranges or fluctuates with intermittently positive PEth—specifically, do you require a documented period of reduction/abstinence before treatment, or do you start therapy with a modified monitoring/futility framework?
Typically, my approach is to ensure that alcohol is not contributing to their liver disease before initiating anti-fibrotic therapy. I usually counsel them and monitor their PETH testing serially. Sometimes, cutting out alcohol itself will help reduce their fibrosis level over time and may obviate t...
In suspected antibiotic-associated cholestatic DILI with jaundice and no obstructing lesion on MRCP, what specific clinical or laboratory trajectory triggers you to proceed to early liver biopsy to evaluate for evolving vanishing bile duct syndrome rather than continued close outpatient monitoring?
This is an important question because early awareness and a confirmed diagnosis will result in a better outcome. 1- Needs a clear history and exclusion of other potential etiologies. 2- Need to know whether the patient has underlying liver disease, i.e., metabolic dysfunction-associated steatotic li...
In patients entering AUD treatment who also have obesity/diabetes (a MetALD phenotype), how do you modify your thresholds for fibrosis assessment and for initiating AUD pharmacotherapy and metabolic therapy (e.g., GLP-1 receptor agonists) with the explicit goal of reducing future liver and cardiovascular events?
In patients with a MetALD phenotype entering AUD treatment, I do not lower fibrosis assessment thresholds but rather focus on the higher pre-test probability that they may have significant liver fibrosis; I apply standard guideline-based NIT cutoffs while ensuring timely and complete evaluation. I u...
How do you approach the workup for a patient with imaging showing features suggestive of cirrhosis?
It is important to clarify what features of the imaging are resulting in this diagnostic impression. Liver nodularity without other findings of cirrhosis is non-specific and does not make a diagnosis of cirrhosis. An incidental finding of a nodular liver with normal liver enzymes and normal platelet...
Do you recommend restarting a GLP-1RA after bariatric surgery if the patient tolerated it before the surgery?
While there are no clear recommendations on whether/when to resume GLP-1 RA after bariatric surgery, current 2025 guideline statements (ASMBS, ADA, AACE, Obesity Society) and expert consensus documents suggest the following approach: Hold GLP-1RA in the acute perioperative period. For daily-dosed ...
When starting GLP-1 R agonist therapy for weight loss purposes, how do you counsel patients on duration of treatment therapy?
I counsel people that I expect this to be lifelong therapy (similar to how we don't stop blood pressure medications when blood pressure comes down to normal on them because it will go back up, we don't stop GLP1RA when we get to our weight goals, as our weight will go back up when they are stopped)....
How do you counsel patients on semaglutide or tirzepatide in light of potential cancer risks?
Use of GLP 1 RAs has sky-rocketed in recent years due to what seems to be a positive class effect on T2DM, weight loss, renal outcomes, cardiac outcomes and hepatic outcomes. I am not aware of any signals of increased malignancy risk. A brief literature review found meta-analyses showing possible be...
In patients with F2/F3 fibrosis, would you start Resmetirom if they had normal liver enzymes?
Yes, it would be reasonable, especially if you can prove that they still have significant steatosis (such as a CAP of >300 db/m) or active MASH on liver biopsy, as Resmetirom works by directly removing fat from the liver. The lack of liver enzyme elevation is not a reliable sign to rule out steatohe...
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...
When using vasoconstrictors for HRS-AKI, what MAP target do you use in practice (absolute MAP vs ΔMAP), and how do you adjust that target in patients with chronic hypertension, cirrhotic cardiomyopathy, or very low baseline MAP?
Aim for a mean arterial pressure (MAP) at least 10 mmHg higher than baseline when treating with norepinephrine. For terlipressin, it is not necessarily titrated to a MAP, but you will see an increase in MAP as a response.