Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
Do you continue semiannual HCC surveillance after HBsAg loss in a non-cirrhotic patient with additional risk factors (e.g., first-degree family history of HCC and ongoing alcohol use), and what criteria drive that decision?
No
What is your approach to peri-operative risk stratification and optimization in patients with cirrhosis?
The VOCAL-Penn score is one piece of information that I use for risk stratification in patients with cirrhosis. I usually treat symptomatic decompensated cirrhosis first (hepatic encephalopathy, ascites, hepatic hydrothorax, hepatorenal syndrome, variceal bleeding), because the risk scores usually c...
In patients with GERD, when should Baclofen or alginate-based therapies be considered, and which patient characteristics warrant caution when using these treatments?
Baclofen and alginate-based therapies are adjunctive, phenotype-directed options for actionable GERD symptoms refractory to optimized proton pump inhibitor therapy. Baclofen reduces transient lower esophageal sphincter relaxations and is most effective in regurgitation or belching predominant phenot...
Do you add elafibranor or seladelpar to UDCA within the first year of treatment in a patient with primary biliary cholangitis who has an inadequate alkaline phosphatase response but no symptoms of pruritus?
I usually will wait for a year with the first line agent, ursodiol, if it is well-tolerated and there are no symptoms, before declaring inadequate alkaline phosphatase response and moving on to a second line agent for primary biliary cholangitis.
How do you counsel patients about the potential benefits of laxatives when they are experiencing overflow diarrhea and are concerned about it getting worse with these medications?
I'll preface this by saying I rarely see this, and I will approach this answer as if this patient were in palliative care. But I think I would start with education on the mechanism of this type of diarrhea and the rationale for using laxatives to improve the situation. I would also discuss that, aft...
What clinical features would raise your suspicion for IgG-4 related disease?
IgG4-related disease can affect multiple organs, leading to varied presentations. In the abdomen, patients can have symptoms secondary to pancreatitis and or biliary obstruction. In the liver, patients can present with a PSC-like picture (jaundice, cholangitis, ductal strictures/dilatation) that, un...
What therapies have you found most effective for JAK-induced/associated acne (JAKcne)?
Doxy will work quickly and is pretty safe. If all goes well, you can taper the dose of the oral antibiotic and use topical agents.
How do you approach using fecal microbiota therapy for recurrent Clostridioides difficile infection in immunocompromised patients?
We generally do not do the single donor FMT via colonoscopy, that was popular 5-10 years ago. We do offer both the oral and enema-based products, with a slight preference for the oral-based product due to ease of use.
If a patient has persistent ascites requiring diuretics after TIPS, at what point do you consider re-evaluation of TIPS?
Some may still require some diuretics, particularly if lower extremity edema is an issue post-TIPS. Otherwise, if paracentesis is needed ~6 weeks after TIPS and the patient is free of HE, then consider IR dilating the TIPS further. When TIPS is for ascites, IR should really start with a small calibe...
Should asymptomatic esophageal candidiasis identified incidentally on endoscopy be treated?
Yes, in our practice, we do treat asymptomatic esophageal candidiasis when found incidentally on endoscopy. A few things to consider: 1) While patients may be asymptomatic at the time of the endoscopy, untreated disease can lead to the future development of complications/symptoms, such as odynophagi...