Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
What is your approach to choosing a particular advanced therapy based on patient or disease factors when initiating treatment for moderate-severe IBD?
The selection is based less on relative efficacy and safety (aside from JAKs) and more on the patient: Age, gender, family history, and co-morbidities. Younger males: more concern regarding lymphoma with thiopurines. Young women: If contemplating pregnancy would consider biologics vs small molecule...
How do you incorporate intestinal ultrasound in the care of patients with inflammatory bowel disease?
The use of intestinal ultrasound (IUS) has significantly impacted how I care for patients with IBD. In an established patient with IBD, I typically monitor disease activity every 6 months with a reliable tool (IUS, calprotectin, colonoscopy, or enterography), even when patients are asymptomatic, as ...
What role do you feel there is for antibiotics in the management of severe perianal Crohn's disease?
Without access to biologics you still should have access to a thiopurine. That has some efficacy and was all we had prior to biologics along with chronic antibiotics.
How would you approach new-onset large vessel vasculitis in a young patient with Crohn's disease?
Patients with Crohn's Disease (or IBD) can develop features of large vessel vasculitis or even other forms of vasculitis. The first consideration in a young patient would be determining the type of vasculitis--whether there is a distribution and clinical picture suggestive of TAK. It is important to...
What diet do you recommend for patients with inflammatory bowel disease?
This is a good question and very commonly comes up. The first step is really understanding what the expectations and goals are. If the goal is to achieve remission in people with inflammation who are symptomatic and want to use diet as monotherapy or in conjunction with meds, I discuss various thera...
How do you adjust medications for patients with eosinophilic esophagitis who responded to budesonide or PPI, and when do you repeat EGD?
Repeat EGD after BID PPI is normal- do you decrease to once-a-day PPI? When to repeat EGD if ever? I try to decrease to once daily in the morning, but if so, I repeat an endoscopy 3 months later to make sure histologic remission is still maintained. After response to Budesonide, continue life-lo...
How would you approach diagnosis of a patient with recurrent episodes of abdominal pain, severe myalgias, low grade fevers and urticaria?
Without the mEFV variant, from a rheumatologist viewpoint, the differential includes IBD, a periodic fever syndrome such as FMF or FCAS, and MCAS. Therefore, I would consider that workup with genetic testing (anyone can send!), fecal calprotectin, and MCAS eval with A/I. I don't think of urticarial ...
What factors do you consider when a patient with acute severe ulcerative colitis flare responds to inpatient Infliximab, and you are deciding whether to switch to subcutaneous or continue IV maintenance dosing of Infliximab?
Patients admitted with acute severe ulcerative colitis typically have higher drug clearance related to significant fecal loss of infliximab through a highly inflamed colon, leading to low levels and often the need for dose escalation. There have been studies showing that infliximab levels in severe ...
Would you consider Resmetirom in a patient with metabolic risk factors and persistently elevated transaminases despite lifestyle changes, after a negative workup for other liver diseases, with noninvasive testing suggesting minimal fibrosis (F0–F1)?
Resmetirom is only approved for MASH with F2-3 fibrosis, so it will likely not get approved. If there is evidence of continued hepatic steatosis and no other competing etiologies, would continue current lifestyle recommendations and repeat fibroscan, ELF, or MRE in 1 year. If competing etiologies (e...
What is your treatment algorithm for solitary hepatocellular carcinoma, 3-5 cm, non-operative candidate but Child-Turcotte Pugh A/B?
This really boils down to two issues: CTP score and size of the lesion. For patients who are CTPA with a lesion <3 cm, RFA/MWA or SBRT are good options although there is some data from the University of Michigan (Wahl et al., JCO 2014) that lesions > 2 cm are better served with SBRT. For solitary le...