Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
For remote liver transplant recipients back under the care of a community gastroenterologist (or PCP), what should be the approach to new liver enzyme elevations?
Elevated liver enzymes in post-transplant patients who live far from their transplant center are a common challenging issue. Many factors will influence your recommendation to the local physician: height of enzyme elevation, cholestatic, hepatitic, or mixed profile, and associated symptoms (pain, fe...
How do you decide which patients with upper GI bleeds should be monitored on telemetry?
Telemetry use has some standard indications in GI bleeding, specifically for patients with hemodynamic instability and significant cardiac comorbidities. Such situations include unresolved hypotension, >4 units transfused, known arrhythmia, and severe HFrEF. In these cases, I’m worried about someone...
How do you balance the need for diuretics from a volume perspective (Ex: ascites, edema) in decompensated cirrhotic patients and progressive renal dysfunction?
There is no discrete answer to this question. Much depends on the overall goal of care. For a transplant candidate, higher creatinine may be needed for transplant access and be tolerated, but risk need for post-transplant RRT. If goals are palliative, symptom control supersedes renal function.
In a patient with low (or normal) BMI but findings of steatosis on imaging, no cardiometabolic comorbidities, and very elevated CAP scores, what are your next diagnostic and therapeutic steps to identify the cause of their steatosis and subsequent management?
In addition to knowing the level of steatosis, liver stiffness values would be of most interest. Alcohol use should stop if there is any level of fibrosis. Lifestyle modifications (dietary/exercise) should be part of recommendations, but with a goal of around 5 % weight loss. If they have F2-3 fibro...
How do you manage/treat acute radiation-induced enteritis?
I have no problem with the excellent comments already made. However, I think it is important to add some comments. First - one needs to be sure that the patient truly has radiation enteritis. Many patients receiving abdominal radiation therapy have other issues that need to be explored first. For ex...
How would you approach the diagnosis and management of a patient with features of portal hypertension but normal HVPG and no cirrhosis on biopsy, in the setting of possible but atypical primary biliary cholangitis, and how would you evaluate for alternative causes of presinusoidal or non-cirrhotic portal hypertension?
PBC can sometimes present with non-cirrhotic portal hypertension, like nodular regenerative hyperplasia, but your patient's normal HVPG argues against this. Having said that, HVPG is not great for measuring presinusoidal portal hypertension. Given the "atypical" nature of your patient's PBC, I would...
What is your strategy in the management of patients with autoimmune hepatitis who failed azathioprine therapy and what parameters do you monitor with what frequency?
Great question. Around 10% of autoimmune hepatitis cases don't respond to azathioprine (AZA) and 15% may have an incomplete response to AZA. These patients require second-line therapy. Before initiating second-line therapy, it's important to exclude non-adherence. Mycophenolate Mofetil (MMF) is the ...
Which GI cancer patients do you use oral contrast in staging CT scans?
We do not use oral contrast for most of our patients and only offer oral contrast CT scans for patients we are concerned about perforation.
In a patient with unresectable HCC who developed immune-related colitis with the first dose of tremelimumab/durvalumab, would you consider continuing durvalumab alone after resolution of the colitis with steroid treatment?
I haven’t seen too many TREMI/DURVA colitis cases, but basing experience off of BOT/BAL, which is notorious for the CTLA-4 inhibitor-related BOT-colitis, as well as some patients who have had IPI/NIVO colitis, or any grade ≥3 event in the combination setting, it’d be reasonable to continue the PD1/P...
What surveillance is recommended for a C1M3 segment of columnar-lined esophageal mucosa with repeated biopsies demonstrating columnar metaplasia but no goblet cells/intestinal metaplasia across multiple endoscopies?
Based on current U.S. guidelines, routine endoscopic surveillance is not recommended for columnar-lined esophagus without intestinal metaplasia (goblet cells). The American Gastroenterological Association (AGA) does not consider this Barrett's esophagus and does not recommend using that term or perf...