Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
What are your next steps for a patient with gastritis on histology without NSAID use and H. pylori negative?
Gastritis is often reported on histopathology, but without more specifics from the pathologist, it has limited clinical utility. In my experience, qualifying the pattern and extent of gastritis can provide more guidance on subsequent management. The endoscopist should assess and document the visual ...
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...
What surveillance is recommended for a C1M3 segment of columnar-lined esophageal mucosa with repeated biopsies demonstrating columnar metaplasia but no goblet cells/intestinal metaplasia across multiple endoscopies?
Based on current U.S. guidelines, routine endoscopic surveillance is not recommended for columnar-lined esophagus without intestinal metaplasia (goblet cells). The American Gastroenterological Association (AGA) does not consider this Barrett's esophagus and does not recommend using that term or perf...
What is your preferred analgesic in patients with small bowel obstruction or ileus?
I typically use IV Tylenol ATC if fully obstructed, and IV Toradol if no other contraindications to NSAIDs (and they often are quite prerenal or losing a lot of fluid from an NG tube, so I often don't feel comfortable with more than a couple doses, and if I think they are going to the OR, I do not u...
How do you approach HCC screening in patients with advanced fibrosis e.g., F3 on FibroScan?
We should first understand the underlying principles that defined the various cut-offs that resulted in this recommendation (eg, cost-effectiveness threshold for HCC screening, cut-offs for advanced fibrosis) and then go from there. Among patients with cirrhosis, the cost-effectiveness threshold wa...
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...
Do you avoid peritoneal dialysis in cirrhotic patients with ascites?
There are two major concerns regarding the performance of PD in patients with ascites: the potential for fluid leakage at the site of the newly placed catheter and the perceived increased potential for peritonitis. In my experience, neither of these is a compelling reason to shy away from PD in a pa...
What techniques do you find most effective for visualization of rectal disease with intestinal ultrasound?
I am not sure that this is the correct use of "intestinal ultrasound". There is the transabdominal ultrasound technique that is taught to gastroenterologists who can use it at point of care for their UC and CD patients to assess the small bowel and the colon. If you want to specifically look at the ...
In light of recent measles outbreaks in the US, would you recommend an MMR booster for immunocompetent patients born before 1957?
I would not recommend a measles vaccine for a person born before 1957. This year has been chosen because people before born before 1957 have a very very high likelihood of having had measles because virtually all children got this highly contagious disease. On the other hand, there is no harm to get...
What are your go-to medical management options for high ileostomy output in patients with >100 cm of remaining small bowel?
First of all, you have to make sure that the patient's liquid intake is not composed of free water but an electrolyte solution at least 50% of the time. Metamucil at night Nana flakes in a milkshake at night Medication stepwise: Maximize loperamide Add diphenoxylate Add a PPI to reduce acid secre...