Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
Where do SIBO testing and/or empiric antibiotics fit into the management of patients with bloating, abdominal pain, diarrhea, constipation, or distention?
There are now consensus papers on breath testing from North America, Europe, Asia (and Australia), Brazil, and, most recently, Argentina. All state that SIBO testing is important in the management of these functional symptoms. We have shown that methane is a cause of constipation, and Hydrogen on br...
Do you use lactulose in acute liver failure, particularly in patients on continuous renal replacement therapy (CRRT) for ammonia or toxin clearance?
Generally lactulose should be avoided in the situation given limited benefit as well a tendency for ileus in ALF and potential for lactulose to cause bowel distention.
How do you manage anticoagulation/antiplatelet therapies with strong indications for uninterrupted therapy in the setting of urgent procedures?
If anticoagulation is absolutely contraindicated because of the bleeding risk of the procedure, then "bridging" will usually make the most sense, most of the time, with low molecular weight heparin such as enoxaparin. If dual antiplatelet agents are contraindicated, particularly in the first month a...
How do you approach the diagnosis of hepatorenal syndrome in a patient with cirrhosis and AKI who has not responded to albumin resuscitation but has a recent nephrotoxic exposure that could explain the renal dysfunction?
If the nephrotoxic exposure (e.g., aminoglycoside) is known to cause ATN, then the findings of low urinary sodium/fractional excretion of sodium, a bland urinalysis, and no structural abnormalities on renal ultrasound should make one consider HRS as the etiology of the AKI. The findings of granular ...
Would you consider the use of prophylactic antibiotics in patients admitted with decompensated cirrhosis with AKI with Cr>1.2, with ascitic fluid protein <1.5 without SBP and/or hyponatremia/Bili >3?
Is this in generalized cases or cases of GIB? If GIB, yes, I would consider it. In just generalized cases, there is no real role for empiric antibiotics.
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...
When noninvasive tests are discordant (e.g., low FIB-4 but elevated VCTE and ELF), what is your decision algorithm for initiating a GLP-1 receptor agonist for MASH, and what specific discordance threshold makes you revert to biopsy?
I rely more on vibration-controlled transient elastography (VCTE) than the Fibrosis-4 (FIB-4) index or the Enhanced Liver Fibrosis (ELF) score. I use FIB-4 as more of a screening tool to inform next steps rather than a definitive diagnostic assessment of fibrosis. If I am wary of my VCTE results, I ...
In young, non-cirrhotic HBV–HDV coinfection with minimal fibrosis on elastography, do you perform lifelong 6-month HCC surveillance based on HDV status alone, or do you modulate surveillance intensity based on fibrosis trajectory and treatment response?
There are two separate issues. The frequency of liver cancer stent with used to initiate. It is not dependent on the risk of cancer. It is related to the doubling times of cancer in the ability to detect cancer when they are small, which is why a six-month interval is always chosen. While the rest ...
What initial workup do you perform when there is a concern for porphyria?
This is a terrific question. But a broad question. Porphyria refers to a defect in heme biosynthesis leading to the accumulation of porphyrins and porphyrin precursors. We should remember that there are three general categories of porphyria based on clinical manifestations: acute hepatic porphyria (...
How do you determine whether to limit volume removal during therapeutic paracentesis in a patient without acute or chronic kidney disease?
Large volume paracentesis (LVP) can lead to complications such as post paracentesis circulatory dysfunction. In patients who have ongoing acute renal failure, patients with borderline low blood pressure, or in patients who have a history of hyponatremia, LVP should be limited to 5L.