Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
How would you approach interval worsening of pancreatic fluid collection with the development of "extensive pancreatitis" on imaging without elevated lipase, any abdominal pain, nausea, or vomiting?
Well, naturally, knowing additional details and seeing an image would be important, but based on what I am hearing, I would recommend a few things: If the cross-sectional imaging indicates pancreatic fluid collection, it is important to know when the initial pancreatitis occurred. The more mature th...
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)...
What is your approach to terminal ileal structure in the setting of a new diagnosis of Crohn’s disease on index colonoscopy?
If there have been episodes of symptomatic obstruction or if there is proximal dilation on imaging, I would forgo any medical therapy and move straight to resection.
In a patient with intermittent pouchitis who has up to 3 acute pouchitis episodes that respond well to antibiotics, how do you manage leakage of stool, especially at night?
Leakage at night is an expected outcome in a pouch patient. Women who have given birth or older patients who have weaker anal sphincters are susceptible to this. First, make sure they do not have cuffitis or pouchitis. Anorectal manometry will identify this with depressed pressure/tone. A cotton ple...
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? How do you navigate insurance coverage?
The answer to this question depends on a variety of factors, including which advanced therapy is being used, the phenotype of the patient’s IBD, the number of previously failed treatments, and the degree of symptoms. I do not expect patients to be in complete clinical remission by the time induction...
What is your approach to symptom management in patients with infectious diarrhea?
When it comes to infectious diarrhea, I would consider a short course of loperamide for symptomatic relief, provided that my suspicion for C. diff colitis and/or dysentery is low. Antimotility agents in the setting of toxin-producing infectious diarrhea can increase the risk of toxic megacolon (in C...
How do you decide when to use acid-suppressive medications for GI prophylaxis when patients are on prolonged corticosteroid therapy?
We only use acid-suppressive medications for GI prophylaxis in patients treated with corticosteroids when they have additional risk factors for upper GI bleeding. Risk factors include concomitant NSAID or antiplatelet therapy, history of GI bleeding or peptic ulcer, age over 60 years, prednisone dos...
What vitamins and minerals do you check yearly for patients post gastric bypass surgery?
Following Roux-en-Y gastric bypass it is essential to monitor micronutrients, vitamins, and minerals because malabsorption and long-term complications may occur with improper care. Based on ASMBS 2016 Nutrition Guidelines, AACE/TOS/ASMBS 2019 updates, and Endocrine Society recommendations, here are ...
Would you use upfront atezo/bev in a patient with HCC and untreated hepatitis?
Yes. I would not have concerns. For HBV, I would start treatment before or simultaneously. Studies have varied by protocol about the HBV viral load being under 500 or 100 but it is not clear this matters. There have not been flairs reported. In regards to HCV, again, not an issue for me.
In patients with iron deficiency due to history of gastric bypass or IBD, would you consider oral iron therapy if the iron deficiency anemia is mild?
Oral iron can often be effective in iron deficiency, as long as absorption is intact. If you are concerned about absorption, performing an oral iron challenge can be useful in allowing you to avoid long trials of oral iron that will be ineffective. Simply check an iron panel at baseline, then admini...