Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
When do you consider de-escalating therapy such as dupilumab in eosinophilic esophagitis?
It is first important to recognize that EoE is a chronic condition. In a patient whose EoE is successfully being treated (whether it be with PPI therapy, swallowed steroids, food elimination, or dupilumab), the disease will invariably become active again over time if therapy is stopped. This is why ...
If a young patient with biopsy proven EOE is doing well on bid PPI, when would you consider switching to Dupixent in order to precent long term complications such as strictures?
If the patient is in proven histologic remission on PPI and the symptoms are well-controlled, then the patient has PPI-responsive EoE and can stay on PPI as maintenance therapy. There is no indication for switching to Dupixent in this scenario except for patient preference. There is no current evide...
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...
How do you diagnose and manage suspected opioid-induced esophageal dysfunction?
Patients with opioid-induced esophageal dysfunction have symptoms of most often, chest pain or dysphagia, with manometric findings of EGJ outflow obstruction, type 3 achalasia, or esophageal spasm/hypercontractile/jackhammer esophagus. When manometry suggests EGJOO or type 3 achalasia, in our practi...
When would you phlebotomize patients with secondary hemochromatosis, such as due to NAFLD/cirrhosis?
My simple answer is “rarely, if ever” (but it can get much more complicated). Related to hepcidin changes, patients with chronic liver disease frequently have elevated serum ferritin and transferrin saturation, more so with alcoholic liver disease and non-alcoholic fatty liver disease. It is far fro...
In a patient with dysphagia and manometry showing diffuse esophageal spasm or ineffective motility plus positive pH study, how long should GERD be treated before reconsidering the diagnosis of achalasia, and what additional testing should be pursued?
In this case, optimal treatment for GERD (twice daily PPI) should continue for 8 weeks. If symptoms persist, I would first consider repeat reflux testing on PPI to ensure that reflux is well-controlled on optimized therapy. If not, escalation of reflux treatment may be needed. On the other hand, if ...
What is your approach to work up and management of a patient with advanced HIV and poor adherence to therapy presenting with dysphagia and fever?
I would first do an HPI (is the dysphagia for both liquids and solids?), then a quick physical exam, with a full set of vital signs. In terms of basic blood work, I would get a CBC and BMP, liver function tests, a set of blood cultures, a chest x-ray, along with a viral load and CD4 T cell count, wh...
Which patients, if any, do you revert back to ultrasound screening for HCC after prior diagnosis/definitive treatment of HCC?
I don't revert back to U/S for these patients ever. It's not dissimilar from colorectal cancer screening - once you have colon cancer, it's not appropriate to use iFOBT or stool DNA screening anymore - it's lifelong colonoscopy screening. Likewise, for HCC, I continue to use AFP plus cross-sectional...
What are your vaccine recommendations while patients are on biologics?
Live vaccines are best completed at least a month before initiation of biologics when these are appropriate (e.g., MMR, chickenpox, yellow fever). The data on non-live vaccines is limited. I personally think that some degree of protection is better than none. I will not interrupt biological therapy ...
How do you decide between anticoagulation and observation for an incidentally detected subsegmental pulmonary embolism in elderly patients with a history of gastrointestinal bleeding?
We face this conundrum not infrequently because subsegmental emboli are subject to high inter-reader variability, and the accuracy of the finding in isolation is suspect (Batayneh et al., Blood 2023). I once mentioned this to a radiologist who reads CTAs and was told, tactfully, that I was full of i...