Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
How do people approach non-HIV patients with hepatitis B, a negative Hepatitis B E antigen, normal LFTs and relatively low HBV DNA between 2000-20000?
Treatment of chronic Hep B is recommended to prevent maternal-fetal transmission, reactivation during chemotherapy, recurrence after liver transplantation, and in patients with decompensated cirrhosis. Treatment has been shown to reverse fibrosis and cirrhosis. Specifically referring to the above sc...
Can fatty liver disease present with elevations in alkaline phosphatase without other liver enzyme elevations (AST and ALT)?
It is very atypical but can occur. Patients usually have elevations in aminotransferases (usually ALT higher than AST) and there can be very mild concurrent elevations in alkaline phosphatase. An isolated alkaline phosphatase elevation should however prompt a more extensive serological work up as we...
Would you start a biologic without a tissue diagnosis in a young male presenting with recurrent small bowel obstruction and MRE showing distal ileitis, which was unable to be reached despite repeat colonoscopy?
Thank you for your question. Not sure what “young” is, but in the differential are lymphoma and an inflamed Meckel’s diverticulum. You absolutely need tissue before you commit him to a biologic. Steroids can help with a lot of different things and should not be considered a diagnostic criterion for ...
In what scenario do you obtain ammonia levels in a patient with cirrhosis?
Very few people check ammonia levels now in patients with cirrhosis. It turns out that it’s not a really accurate measure, and it’s also difficult to draw and get to the laboratory. I think we need to use clinical judgment to diagnose encephalopathy and, of course, the opinion of close relatives.
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 would you approach endoscopic diagnosis and treatment of an area of visible nodularity concerning for cancer within long segment Barrett’s esophagus?
I would begin by careful inspection of the Barrett's (BE) mucosa under HD-white light and narrow band imaging after washing off the surface mucus. I would evaluate the entire BE segment for nodules, ulcers, irregularities in pit-pattern and focal changes in vascular pattern, raising suspicion for in...
Would you pursue a colonoscopy for a patient in their 20s with constipation and rectal bleeding if they had a first-degree relative who died young from a "carcinoid tumor"?
Carcinoid tumor is relatively uncommon in someone who is relatively healthy and young. I would make sure to consider all the more common diagnoses and workup before considering carcinoid tumor. Moreover, carcinoid tumor is associated with diarrhea rather than constipation. Neuroendocrine tumor of th...
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.
How long do you recommend waiting after variceal bleeding and banding before a transesophageal echocardiogram can be performed safely?
In the exact wording of this question, the scenario that is being presented is that the patient has had a variceal hemorrhage (VH) recently and urgent banding has already been performed to stop the VH (so that the concern would be of the TEE probe knocking off a band that is actively treating an eso...
What is your preferred screening tool for colon cancer in an average-risk patient?
For their first time screening, I universally recommend a colonoscopy (in the absence of contraindications or social barriers) to evaluate for polyps, followed in 5-10 years by a yearly FIT or Cologuard every three years (unless the patient has a strong preference for a repeat colonoscopy). Repeat c...