Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
How do you approach the treatment of Crohn's colitis in the setting of immunosuppression for liver transplant?
Good question, as additional immune suppression can increase the risk of infection. The anti-rejection drug mycophenolate can cause diarrhea, which could mimic a Crohn’s flare. I individualize Crohn’s therapy in a liver transplant patient. What type of Crohn’s do they have? What meds were they on pr...
How do you decide whether to place an NGT or PEG tube in patients with dysphagia precluding adequate PO nutritional intake?
There are several factors that go into the decision of PEG tube vs continued nutrition via a nasogastric feeding tube(NGT). Anticipated time to recovery of oral pharyngial function (especially in the most common underlying illness, which is stroke). NGT can stay in place for up to 2 months without...
How do you manage anticoagulation/antiplatelet therapies with strong indications for uninterrupted therapy in setting of urgent procedures?
If anticoagulation is absolutely contraindicated because of the bleeding risk of the procedure, then "bridging" will usually make the most sense, most of the time, with low molecular weight heparin such as enoxaparin. If dual antiplatelet agents are contraindicated, particularly in the first month a...
What is your advice to patients with IBD who are on biologic therapies and planning for pregnancy?
Biologics are effective therapies for many autoimmune conditions, including IBD. The best outcome of a pregnancy is if a patient is in remission at the time of conception, which means she does not stop her therapy to get pregnant. Indeed, there are studies on women with nonspecific infertility who w...
Would you consider anti-IL-5 therapy (mepolizumab or benralizumab) to either prevent or treat the more severe manifestations of eosinophilic granulomatosis with polyangiitis, such as "infiltrative" (e.g., cardiomyopathy, pulmonary infiltrates, or gastroenteritis) or "vasculitic" (e.g., neuropathy, palpable purpura, or glomerulonephritis)?
Yes, I would consider early starting biologics for infiltrative EGPA.
Can rapid weight loss following GLP1 R agonist therapy lead to postprandial hypoglycemia and if so, what are the treatment options outside of dietary modifications?
This is a very interesting question but I am not sure that there is a clear published answer. Of course, we know that this class of medications can contribute to hypoglycemia in patients on insulin or SUs and in that situation the management would involve cutting back on the insulin or SU or decreas...
How do you manage a patient with Ogilvie's syndrome presenting with a cecal diameter above 12 cm unresponsive to conservative management with electrolyte correction, decompression by flexible sigmoidoscopy, and rectal tube placement?
While neostigmine has traditionally been used in this setting, it often faces pushback from both the hospital and pharmacy due to the need for cardiac monitoring. Additionally, it's not suitable for long-term use. Instead, I’ve been using pyridostigmine, which does not require cardiac monitoring and...
Is there benefit to aggressively treating hemochromatosis in a patient who has already progressed to cirrhosis at the time of diagnosis?
The short answer is yes, there is a benefit to treating iron overload in a patient with hereditary hemochromatosis (HH) with cirrhosis. HH involves at least five mutations, most commonly in the HFE gene (common variants include C282Y and H63D), leading to hyperabsorption of iron and progressive accu...
How do you plan to integrate exercise programs after adjuvant chemotherapy in patients with colon cancer, given the results of the CHALLENGE trial?
The CHALLENGE study demonstrated that structured exercise following adjuvant chemotherapy significantly benefits patients with resected high-risk stage II or stage III colon cancer. The study's success hinged on its mandatory behavioral-support sessions. Unlike the control arm, which received only h...
With the growth of non-alcoholic beverages (e.g., NA beer, liquor, etc), how do you approach a patient's consumption of these products in the setting of alcohol related liver disease?
This is definitely a challenging conundrum to deal with. Historically, even the NA beverages would have 0.5% alcohol, so they weren't truly NA. With time, that has seemingly changed. Regardless, my approach is the same. I strongly advise against the idea that NA beverages are allowed. Mostly because...