Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
Do you recommend starting naltrexone at discharge for alcohol use disorder in patients with decompensated cirrhosis secondary to alcohol use?
Although naltrexone is generally safe to use in patients with cirrhosis, I would be cautious to use it in patients with decompensated cirrhosis, since it is mainly metabolized in the liver. I usually use acamprosate in patients with decompensated cirrhosis, with high bilirubin, as long as renal func...
What kind of monitoring do you choose in patients at risk for reactivation of hepatitis B who are on immunosuppression?
For patients at high risk of reactivation, I initiate prophylaxis and, given high efficacy, I don’t routinely monitor (other than to schedule annual appointments to make sure patients are getting refills). Generally, these patients are getting routine labs done by their oncologist or rheumatologist....
When do you pursue liver biopsy for assessment of DILI?
In the setting of an acute elevation of liver chemistry tests, DILI should always be considered in the differential diagnosis. If the serological workup for abnormal liver tests is unrevealing as well as abdominal imaging, expectant management should ensue with the discontinuation of any potential o...
What factors into your choice to use craving-related medications (e.g., baclofen, naltrexone, acamprosate, etc.) in the management of alcohol use disorder?
When I discuss starting medications of alcohol use disorder (MAUD), we discuss reducing alcohol cravings, thereby reducing overall intake with the ultimate goal of abstinence with adjunctive psychotherapy if necessary. The options currently available in the market are naltrexone oral and intramuscul...
How do you incorporate other pharmacologic bariatric/appetite suppressants in the context of their clinical care plan for MASLD?
Patients with MASLD have different risk factors and drivers of disease (obesity, diabetes, eating disorders, etc). I lend personalized and individualized care when developing a care plan for patients with MASLD, including the risks, benefits, and alternatives to bariatric surgery (for those patients...
How does presence of clinically significant portal hypertension change patient prognosis in MASLD?
The presence of CSPH based on HVPG or the Baveno criteria (LSM on VCTE + platelet count) indicates higher chances of decompensation. Data from several clinical trials showed that higher VCTE LSM and lower platelet count are associated with higher annual decompensating event rates. Patients with MASH...
When would you consider use of EUS guided liver biopsy over percutaneous and/or transjugular?
If data (labs, imaging) are not entirely compelling for a primary parenchymal or biliary issue, then EUS liver biopsy can be an efficient approach in addition to ERCP (saving the need for separate biopsy in the event that ERCP is non diagnostic).
How do you rule out spontaneous bacterial peritonitis in a patient with minimal ascites that is not amenable to paracentesis?
You can’t, unfortunately. You either need to keep looking for a good pocket (move patient to each side, etc.) or use clinical judgement and decide whether or not to treat empirically.
Do you recommend CBD cessation prior to screening of liver enzymes?
CBD increases liver enzymes. In a study, it took 1-2 weeks to normalize after cessation. Would recommend ideally 2 weeks, but a minimum of 1 week to remove the noise caused by CBD that may lead to an extensive and possibly unnecessary workup.
How do you approach the management of patients who require nutritional restoration in the setting of a presumed functional GI disorder recalcitrant to behavioral medicine and pharmacologic therapies?
It certainly is a very good question if indeed the patient has functional disease; then, for sure, they need more than just my help. They probably need the help of a nutritionist, but even more so, they need perhaps psychiatric medication and the treatment of a behavioral therapist or psychological ...