Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
What is your approach to terminal ileal stricture 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.
Under what circumstances do you give chemotherapy for a nondiagnostic pancreas biopsy that is suspicious for adenocarcinoma?
Assuming it is a localized pancreatic abnormality and no "metastases," I would not give chemotherapy as such. If anything, I would consider surgical removal, which will also give the exact diagnosis. To start, chemotherapy is not curative (maybe if it were a lymphoma!). There may be some way of doin...
At what BMI or waist-circumference threshold do you opt to move from Fibroscan to other NILDA for fibrosis assessment?
The XL-validation study found a liver stiffness measurement (LSM) failure of 1% for the XL and 16% for the M probe, in patients with a BMI of 28 or above. In people with a BMI of 40 or above, the XL-probe failure was 5%, and the best predictor of failure was a skin-to-capsule distance (SCD) ≥25 mm (...
Are there any biomarkers that might indicate who might be responders to atezolizumab/bevacizumab for HCC?
Not at this time. Some preliminary studies are being done as ad hoc at this point and was not pre specified before the IMbrave study launching
With the latest hepatitis B guidelines and recent phase 3 trial of Bepirovirsen mentioning the utility of quantifying HBsAg levels, how have you incorporated HBsAg in your practice?
Since the first New England journal publication on Bepi (Yuen et al., PMID 36346079), which demonstrated functional cure in patients with less than 1,000 international units of surface antigen, we’ve been quantifying surface antigen in all of our hepatitis B patients. Almost all the large commercial...
Does oral Wegovy have a worse side effect profile compared to its injectable version?
From a clinical standpoint, I would say that oral semaglutide does cause more nausea and other GI side effects than injectable semaglutide for comparable doses. I am not aware of any randomized trials looking at this question, but there are single-center retrospective studies corroborating my impres...
In patients with sarcoidosis and persistently elevated liver function tests, when do you consider initiating ursodeoxycholic acid (UDCA)?
In patients with systemic sarcoidosis with predominantly elevated alkaline phosphatase, I would be suspicious for liver involvement of their sarcoidosis. If treatment of the systemic sarcoidosis with immunosuppression (typically initiated by Pulmonology or Rheumatology) are ineffective for improving...
Do you recommend restarting a GLP-1RA after bariatric surgery if the patient tolerated it before the surgery?
While there are no clear recommendations on whether/when to resume GLP-1 RA after bariatric surgery, current 2025 guideline statements (ASMBS, ADA, AACE, Obesity Society) and expert consensus documents suggest the following approach: Hold GLP-1RA in the acute perioperative period. For daily-dosed ...
How do you decide when to refer for gut-directed psychotherapy versus start pharmacotherapy in newly diagnosed IBS with prominent anxiety symptoms?
Pharmacotherapies like antispasmodics, antidiarrheal medications, or tricyclic antidepressants can be used to treat a specific symptom of IBS (e.g., diarrhea or abdominal pain). Gut-directed psychotherapy targets the entire gut-brain axis in dysfunction, treating multiple symptoms at once, as well a...
In patients with microscopic colitis, what do you recommend on stopping SSRIs?
First, make sure the problem is not NSAIDs, PPIs, or statins. Second, remember that the evidence linking SSRIs to microscopic colitis is not iron-clad. Third, if you want to do a trial of a different class of antidepressant, the evidence linking SNRIs to microscopic colitis is even less consistent.