Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
Would you use upfront atezo/bev in a patient with HCC and untreated hepatitis?
In the case of a patient with untreated chronic hepatitis C, I would offer upfront atezo/bev, as long as hepatic function is appropriate. At our center, hepatitis C treatment is generally not offered to patients with advanced HCC. Interestingly, only 21% of patients treated with atezolizumab/bevaciz...
If you do not have easy access to shear wave elastography (aka Fibroscan), what do you recommend for non-invasive tests to determine if a MASLD patient has clinically significant portal hypertension and risk-stratify them?
Great question. I do magnetic resonance elastography (MRE), and if not possible, shear wave elastography (SWE). If I have access to only blood-based non-invasive liver disease assessment (NILDA), will then order enhanced liver fibrosis (ELF). However, for clinically significant portal hypertension (...
How soon after an acute upper GI bleed do you restart therapeutic anticoagulation in a patient with atrial fibrillation and a high thromboembolic risk (CHA₂DS₂-VASc ≥4)?
In real-world inpatient practice: ~72 hours after endoscopic control for high-stroke-risk AF with stable hemoglobin and no rebleeding. Extending hold to 5–7 days if the lesion is high risk or the bleed was severe.
What is your general approach to an immunocompetent patient with chronic, non-infectious diarrhea?
If the diarrhea has lasted more than a few weeks and all infectious workup is negative, then I'll send serologies for IBD/celiac, especially if there is any weight loss. Where we practice in New York City, these patients almost always end up getting an EGD/colonoscopy.
How do you approach surveillance and repeat biopsies in a patient with a diagnosis of intestinal metaplasia (aka Barrett's esophagus) on pathology who appears to have a regular Z-line or <1 cm of salmon mucosa?
I agree with the other responses to this question. One other aspect that can be tricky in patients where you did not do the index endoscopy is that many patients present with the expectation that they will need further surveillance, or have already been told that they will need surveillance at some ...
In patients with dysphagia and a normal esophagus on endoscopy, when is empiric dilation indicated?
This is somewhat controversial. There is some data that shows that some patients do experience improvement in swallowing following empiric esophageal dilation. This is more so the case in patients with solid food dysphagia, and when dilation does lead to some mucosal tearing. However, other studies ...
What prompts you to obtain esophageal biopsies in patients with GERD who have a normal-appearing esophagus on EGD and no dysphagia?
This is a good question. I do not routinely, unless there are other factors that steer me in the direction of eosinophilic esophagitis (EoE), such as a young patient with extraesophageal atopic disorders, where heartburn may be the presenting symptom of EoE.
If an ulcerative colitis patient has a 90 percent response to a biologic or small molecule after over 12 months, would you consider switching medication to a different class in hopes of getting a complete response, versus trying adjunctive therapy?
I am not sure what you mean by “90%” response. Is that clinical, laboratory, or endoscopic? Perfection is the enemy of good, so you'd better have a compelling reason to make a patient add another therapy.
How would you treat a patient with stage IE gastric MALT lymphoma with negative testing for H. pylori?
Standard of care treatment in these patients mostly includes local radiotherapy. You need to be certain that the patient is truly HP-negative; the gold standard for this is negative histopathology for HP. In patients with negative HP histology, you should still rule out HP with non-invasive measures...
What Barrett's Esophagus screening protocol do you follow for patients with scleroderma given the increased risk of reflux and esophageal stasis?
This is an excellent question and is probably also relevant to mixed connective tissue disorder (MCTD) and overlap syndromes. My answer is a poor one - to my knowledge, we just do not have the data to guide us. I would certainly be more vigilant, but do not have a set protocol other than that for BE...