Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
Do you routinely recommend diagnostic endoscopy for patients with persistent enterococcus bacteremia despite receiving adequate antimicrobial therapy and no clear nidus?
It depends. Did you do an echocardiogram to rule out endocarditis? Urine cultures were negative? Gallbladder ultrasound was negative? CT of the abdomen and pelvis with contrast was negative?Any other symptomatology that accompanied the recurrent episodes of enterococcus bacteremia that could help us...
Do you routinely use single-use duodenoscopes for ERCPs in patients with a history of infections secondary to MDR organisms?
Since we have single-use duodenoscopes available now, it makes sense to use these for patients with a history of MDR infection.
Do you feel there is any difference between performing an ERCP with an EDGE together in a single session or separately in two sessions in a patient with Roux-en-Y anatomy?
Experts do both approaches - I think the minority will do EDGE (or GATE = gastric access temporary for endoscopy, a more inclusive term than EDGE, which is for ERCP only, although GATE only refers to gastric access) with ERCP in a single session as a routine, while more do the 2-step approach. Of co...
Do you recommend, based on current evidence, avoiding antimotility agents in patients with non-fulminant C. difficile infection who have no evidence of ileus?
I generally avoid their use based on the notions that diarrhea may contribute to the elimination of non-invasive GI pathogens and that impairment of intestinal motility could increase the risk of complications, such as toxic megacolon.The data and recommendations have not progressed beyond the follo...
What precautions should be taken when discharging a patient from the medical setting on new medication assisted therapy for alcohol use disorder?
Great question. This article absolutely adds to the argument for using medications for alcohol use disorder. The precautions would mostly explain side effects, just as you would for any new medication. A few specific considerations depend on the medication (I'll restrict this to four more common cho...
Do you prefer formal testing to establish a diagnosis of SIBO/IMO over empiric treatment?
Great practical question. I prefer formal testing for several reasons: Even though postprandial bloating and distention along with change in bowel habits are the hallmarks of SIBO/IMO, they are non-specific and can be caused by myriad of other organic causes. A normal breath test would direct the a...
When and how do you do testing for disaccharidases on GI biopsies?
You can send two biopsies from the 3rd portion of the duodenum for enzyme assays, but it might be easier just to do simple disaccharide absorption tests.
How do you practically approach a tailored elimination diet in young patients with numerous food impactions and esophageal strictures who are intermittently compliant with PPI or topical steroids?
The first thing I would do is discuss with them the different approaches and efficacy of diet therapy. Currently an empiric elimination diet is the favored approach. Which empiric elimination diet is chosen is a discussion to have with each individual patient in a shared decision approach. The six f...
What patient characteristics guide the selection of a step-up versus a step-down elimination diet strategy in the management of eosinophilic esophagitis?
It is a shared decision making between the Physician and the patient. The step-up approach requires fewer endoscopies and may be better tolerated and accepted by the patient. But again a detailed discussion with the patient is needed for any kind of diet strategy to work.
How do you use gut microbiome or gut microbiota analysis in your clinical practice, if at all?
While I am presented with microbiome analyses on a regular basis by patients, I do not believe that these are useful, as we are still not there when it comes to defining the "normal" microbiome. This indeed may vary tremendously between individuals depending on age, gender, diet, geographic location...