Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
What is your approach to liver transplantation candidacy in those with decompensated cirrhosis who have been treated for a solid-organ malignancy, such as oral SCC?
This is an important consideration as patients who receive a solid organ transplantation will be on significant immunosuppression, which can result in significant proliferation of an underlying malignancy and have worse treatment outcomes compared to non-immunosuppressed patients. Furthermore, patie...
How would you approach the management of an incidentally detected subcentimeter nodule located just below/adjacent to the GE junction in a patient without Barrett’s, that is found to harbor high-grade dysplasia (HGD) on pathology following EMR?
I think this depends on the pathology and whether margins were clearly negative. If there is HGD on the margin, I think pt would need further resection, likely ESD, to ensure no dysplastic tissue remains. In addition, careful inspection of the esophagus and stomach under HD-WLI, as well as NBI or BL...
How would you resect an 11mm sessile gastric polyp?
I would first study the surface morphology and pit pattern. Specifically look for central depression or ulceration and signs of early cancer (such as Irregular or amorphous pit pattern). If central depression or irregular or amorphous pit pattern is present, I would consider en bloc resection with E...
How do you manage persistent rectal bleeding in the setting of rectal adenocarcinoma in a treatment-naive patient?
For a locally advanced rectal adenocarcinoma in the era of TNT, treatment of the tumor with either chemoradiation or chemotherapy upfront is reasonable, and both choices are known to palliate colorectal cancers effectively. With more severe bleeding, we often consider starting with chemoradiation th...
In patients with MASLD and F2–F3 fibrosis, would you initiate Resmetirom even if they are not making active lifestyle changes?
Yes, many patients had an underlying metabolic disorder that is difficult/impossible to address with lifestyle interventions alone and will go on to progress in their liver disease if left alone. Now with the approval of Semaglutide in August 2025 by the FDA and the approval of Resmetirom, we have t...
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 ...
With OpenBiome no longer in operation, what is your current approach for obtaining FMT for inpatients with acute severe/fulminant C. difficile infection unresponsive to antibiotics?
Consider Rebyota by enema or flex sig, similar to what you had done with standard FMT.
How long do you treat an isolated bacterial liver abscess which has either undergone percutaneous drainage or for which an indwelling drain is placed?
Until it's gone... Percutaneous drainage of liver abscesses is, in my experience, less effective than drainage of intra-abdominal abscesses, which isn't very effective. Neither type of abscess isn't, as I explain to other doctors and pts, a water balloon. Liver abscesses are more complicated than ot...
How do you choose between resmetirom and semaglutide in the treatment of MASH?
I write a disclaimer to start, because use of resmetirom ($5,000 per month) and semaglutide ($1,600 per month) at this time cannot be used across the board with any patient with hepatic steatosis. It's important to highlight how we characterize a patient's metabolic dysfunction associated steatotic ...
After confirming the patient is not on NSAIDs, how do you approach acute ileitis on biopsies in a patient without symptoms or with only mild loose stools?
Is diarrhea inflammatory? What is her level of calprotectin? A useful biomarker to follow. Aphthous ilieitis does not have risk features for progressive Crohn’s that, at least at this time, does not require an advanced agent. You can use symptomatic agents (loperamide, cholestyramine, etc.) to asses...