Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
How long do you typically treat patients with phentermine for weight loss and what clinical markers do you follow?
Phentermine has been available since 1959 and remains an affordable and effective medication option added to a full lifestyle-based weight management plan. In people who are generally healthy and without contraindications to the medication, I have had patients used in at least intermittently for sev...
For patients with HCC that have stable disease on immunotherapy alone, would you consider adding bevacizumab at the time of disease progression and continue immunotherapy?
Yes, this is applicable to patients who are on single agent immunotherapy, since the atezo/bev combination carries different mechanism of synergistic potential than single agent immunotherapy. Notably, currently approved second line agents are indicated after progression on sorafenib, however, curre...
What factors can lead to falsely elevated fibrosis readings on FibroScan (e.g., consuming sugar before the scan)?
I recommend 3 hours of fasting before performing a FibroScan. Liver stiffness may not be equivalent to fibrosis stages in the following conditions: liver congestion (right-sided heart failure, Fontan-associated liver disease), active liver inflammation (alcohol, active viral or autoimmune hepatitis)...
In a patient with alcohol associated decompensated cirrhosis characterized by variceal hemorrhage that has now “re-compensated” in the setting of alcohol abstinence and is currently on carvedilol, at what surveillance intervals do you perform EGD?
Can apply the latest Baveno VIII consensus to this patient and utilize FibroScan to see if resolution of CSPH to guide whether repeat EGD +/- carvedilol is still indicated.7.19. In patients with recompensated cirrhosis, CSPH resolution/persistence may be non-invasively assessed via liver (LSM) and s...
How do you approach the decision to repeat small-bowel biopsies in a patient with persistent gastrointestinal symptoms, like abdominal pain and diarrhea, when prior biopsies performed years earlier were normal?”
I typically do not repeat small bowel biopsies IF the symptoms have not changed in intensity or frequency. Repeat endoscopic evaluation and biopsies are done in patients with persistent GI symptoms if any changes have occurred: these may include significant worsening of symptoms, of symptoms occurri...
Would you consider long term avatrombopag use in patients with cirrhosis requiring higher platelet counts for medical therapy?
In general, no, I would not use long-term avatrombopag in patients with cirrhosis requiring higher platelet counts for medical therapy due to the perceived thrombotic risk and hemostatic abnormalities of patients with liver disease.One thing to note in assessing the risk of long-term TPO mimetic the...
What is your treatment approach to a patient with budesonide refractory microscopic colitis and multiple sclerosis?
First job is to be sure the colitis is not attributable to any medication, particularly ocrelizumab. Meanwhile, have you given an adequate trial of bismuth?
How do you approach the use of fidaxomicin versus vancomycin for initial Clostridioides difficile infection in immunocompromised patients, considering the lower recurrence rates but higher cost of fidaxomicin?
Whether immunocompromised or not, fidaxomicin has been demonstrated to be superior to vancomycin – not in resolution of the acute infection but in reducing the risk or recurrence by approximately one-half. In one study of hospitalized patients published in 2015, it was reported that, when taking int...
What is your approach to the use of GLP-1 agonists in older adults with diabetes with or at risk of sarcopenia?
This is an important question to keep an eye on, given the broadening use and effectiveness of GLP-1 agonists for various conditions, especially diabetes, and for weight loss. Unfortunately, as is so often the case, major clinical trials in this area do not reflect the heterogeneity of older adults ...
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.