Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
What is your approach to isolated alkaline phosphatase without other laboratory abnormalities?
Assuming none of the other LFTs are abnormal, I would get a GGT. If GGT is elevated --> likely a hepatobiliary issue. Would consider age, medical history, and risk factors. If persistently elevated, could consider RUQ US + MRCP. Conditions like PSC or PBC are frequently discovered due to asymptomati...
Do you avoid the use of GLP-1 R agonist therapy for treatment of obesity in patients with known gastroparesis?
Short answer: yes. Gastroparesis is a well-known side effect of GLP-1 RA therapy. It is dose-dependent, so some patients may tolerate smaller doses but not the highest ones. A recent head-to-head trial of semaglutide vs tirzepatide in obesity (Aronne et al., PMID 40353578) found similar rates of gas...
How do you decide when to initiate or restart diuretics in a cirrhotic patient with ascites if they are receiving a therapeutic paracentesis?
This question has two parts, one with a straightforward answer, the other with a much more nuanced answer, if I understand it correctly. Any patient receiving a therapeutic paracentesis should start/restart diuretics afterwards. Per the 2021 AASLD guidelines, one of the statements reads “LVP is the ...
If an IBD patient has only partial clinical response to a new biologic and or small molecule, do you extend the loading phase before transitioning to the maintenance dose/interval?
As long as the patient is continuing to improve, I try to continue “induction dosing” before transitioning to maintenance dosing. This is particularly true for upatacitinib. We register all our patients with the Pharma companies' patient assistance (bridge) programs to circumvent insurance companies...
How do you rule out spontaneous bacterial peritonitis in a patient with minimal ascites that is not amenable to paracentesis?
You can’t, unfortunately. You either need to keep looking for a good pocket (move patient to each side, etc.) or use clinical judgement and decide whether or not to treat empirically.
At follow-up around 72 weeks, what degree of noninvasive-test nonresponse would prompt you to stop a GLP-1 receptor agonist prescribed specifically for MASH (even if weight and aminotransferases improve), and what objective criteria do you use in the absence of validated futility rules?
When using GLP-1 as liver-directed pharmacotherapy for the treatment of MASH, liver-related endpoints to assess therapeutic efficacy include >/= 30% relative reduction in MRI-PDFF, decrease in ALT >/= 20%, decrease in VCTE >/= 30%, or MRE-LSM >/=20%. Refer to AASLD Guidance for use of semaglutide fo...
In patients with PBC and possible autoimmune hepatitis overlap on immunosuppression, how do you decide whether improvement in ALT/IgG after starting a PPAR agonist reflects adequate control of hepatitic activity versus nonspecific biochemical improvement, and how (if at all) does that influence immunosuppression adjustments?
It is important to establish how convincing the diagnosis of overlap is. I use several different sources of information: Histology: interface hepatitis with a rich lymphoplasmacytic infiltrate (predominant) plus bile duct injury, or bile duct injury predominant with little to no hepatitis. Serum ma...
Would you consider a combination of anti-TNF therapy and azathioprine upfront in a young male with Crohn’s disease considering its risk of lymphoma in the era of several advanced therapies?
Definitely, TNF + IMM hasn’t been beaten in efficacy. If the patient is in clinical and endoscopic remission at 6-12 months with good IFX levels, then they can stop the IMM.
Would you consider sotalol to be a suitable non-selective beta blocker for primary prevention of variceal bleeding in a patient who requires sotalol for treatment of arrhythmia in the setting of Fontan-associated liver disease and clinically significant portal hypertension?
The answer to this question will need to be case-by-case, unfortunately.The short answer:The priority in this patient's case for using sotalol is likely the underlying heart disease and its associated arrhythmia, and this cardiac benefit would not be achieved by carvedilol and other NSBBs. Thus, it ...
How do you approach the management of patients who require nutritional restoration in the setting of a presumed functional GI disorder recalcitrant to behavioral medicine and pharmacologic therapies?
It certainly is a very good question if indeed the patient has functional disease; then, for sure, they need more than just my help. They probably need the help of a nutritionist, but even more so, they need perhaps psychiatric medication and the treatment of a behavioral therapist or psychological ...