Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
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...
How do you approach the workup for a patient with imaging showing features suggestive of cirrhosis?
It is important to clarify what features of the imaging are resulting in this diagnostic impression. Liver nodularity without other findings of cirrhosis is non-specific and does not make a diagnosis of cirrhosis. An incidental finding of a nodular liver with normal liver enzymes and normal platelet...
What are some helpful tips to identify and optimize visualization of the common bile duct on abdominal POCUS?
Good question! The common bile duct (CBD) can be difficult to visualize in general, but optimizing the gallbladder exam will also help to optimize the CBD. I am cautious about ruling out choledocholithiasis with POCUS, though a retrospective 2014 study showed that POCUS can be helpful in ruling out ...
How do you explain the use of an AI scribe to patients the first time it is used in their care?
In residency, we had to get patient permission to videotape sessions and allow our supervisors to watch sessions from behind a one-way mirror. If I were to use a scribe, especially an AI scribe, or if I were audio or video taping the sessions, I would definitely want to get a patient’s approval. I d...
Under what circumstances would you recommend early fecal microbiota transplantation over antibiotic treatment or bezlotoxumab in a patient with recurrent C. difficile infection?
Assuming donor stool is available, if the patient is not expected to need another course of antibiotics in the foreseeable future, I would recommend FMT.
How do you counsel cancer patients when they ask if they should avoid sugar?
“We don’t have evidence to support any specific diet that can either worsen or improve outcomes. I encourage a healthy, well-balanced diet with my top priority being you maintaining your weight during treatment.” Particularly for my head and neck patients, getting in sufficient calories is of the ut...
What clinical scenario do you consider screening for hepatitis delta?
I test every new patient with at least a Delta antibody. If patients have elevated ALT but low level HBV DNA levels, I will get a HDV RNA as my first test.
When can we consider deferring an insulin drip in patients with hypertriglyceridemia-induced pancreatitis?
Serum triglyceride levels >500 mg/dL (5.6 mmol/L) are required for hypertriglyceridemia to be considered the underlying etiology of acute pancreatitis (UpToDate).For patients with severe hypertriglyceridemic pancreatitis, such as those serum triglyceride levels >1000 mg/dL plus lipase >3 times the u...