Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
Do you routinely check Infliximab levels on day 3 with patients admitted with acute severe ulcerative colitis?
The question implies that the patient has received the first induction dose of IFX just three days earlier. If that is the case, day 3 seems too soon to check a level. Normally, we might check a trough level just before the second dose in two weeks. If the level is low, we would increase the second ...
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...
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...
In patients with EGJOO on esophageal manometry, how do you approach subsequent testing for further evaluation?
In order to make a clinically relevant and conclusive diagnosis of EGJOO, patients must not only have manometric findings of EGJOO but also clinically important/related symptoms and at least one additional test which shows evidence of obstruction at the EGJ. This additional testing is with either a ...
How do you approach a patient with endoscopic ileitis without typical features of chronicity on histology, who has worsening abdominal pain and increased stool frequency despite a trial of budesonide?
I am not sure, but I will assume "without typical features of chronicity" means it is either normal or acute inflammation. Acute inflammation is either prep effect, exogenous hormones, or NSAIDs, but this is not Crohn's and would be treated as IBS. If normal, then for sure treat as IBS.
How do you manage a patient with dysphagia whose EGD shows mild esophageal rings and furrows, but histology was negative for interepithelial eosinophils?
That is a great question. The question stem gives the impression that the endoscopic appearance is suggestive of eosinophilic esophagitis. A few things to consider: First, I would make sure that the procedure was done off any treatment, especially PPI therapy. Many patients come for endoscopy alread...
What is your endoscopic approach towards laterally spreading colonic lesions that are over 2 cm in size?
Laterally spreading tumors or LSTs can be of the granular or non-granular type, and the former may have surface nodularity (LST-G-N) and the latter may have a depressed center with different risks of occult cancer and submucosal invasion. LSTs of the nongranular with pseudo-depressed (LST-NG-PD) mor...
What are the target distensibility index and EGJ diameter values on EndoFLIP following peroral endoscopic myotomy (POEM)?
An increase in the intraoperative EGJ-DI following POEM correlates with improved symptomatic response. Persistent DI < 2 is associated with poorer outcomes. When using EndoFlip, our team evaluates patients following POEM by using the 60 mL fill volume and aims for a DI of at least 2.8 and a diameter...
Do you routinely perform serologic testing for systemic sclerosis when absent contractility is identified on high-resolution manometry?
This is a good question. The first thing to consider is the LES pressure. If a patient has elevated LES relaxation pressure on high-resolution esophageal manometry, in combination with absent contractility, then this would be concerning for achalasia type 1 (especially when a patient also has delaye...