Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
What is your approach to managing ILD associated with inflammatory bowel disease?
We must first convince ourselves that the "ILD" relates to the underlying IBD. Patients may be on an immunomodulating regimen that increases the risk of opportunistic infections. The regimen itself may cause diffuse pneumonitis. Environmental/occupational exposures may also play a role. Armed with c...
How would you manage a patient taking a GLP-1 agonist for weight loss who continues to have symptoms (i.e., nausea, vomiting) related to reduced GI motility despite dose adjustments?
Anecdotally, I’ve had good success using prucalopride at twice-daily dosing (0.5 mg BID or 1 mg BID) in select patients. In my experience, tirzepatide tends to be better tolerated than semaglutide from a gastrointestinal perspective.
How would you manage autoimmune pancreatitis in a patient after Whipple's procedure?
There are two types of autoimmune pancreatitis (AIP): type 1 AIP, which is synonymous with IgG4-related disease (IgG4-RD) involving the pancreas and makes up a large majority of AIP cases, and type 2 AIP, which is largely associated with inflammatory bowel disease. I am assuming from the question th...
How do you incorporate intestinal ultrasound in the care of patients with inflammatory bowel disease?
The use of intestinal ultrasound (IUS) has significantly impacted how I care for patients with IBD. In an established patient with IBD, I typically monitor disease activity every 6 months with a reliable tool (IUS, calprotectin, colonoscopy, or enterography), even when patients are asymptomatic, as ...
Do you discharge patients on preventative therapies like octreotide or bevacizumab after a patient's first admission for symptomatic anemia secondary to bleeding from a small bowel AVM that was treated with APC?
Not cost effective
What adjunctive therapies beyond an antisecretory agent (e.g., PPI, H2RA, etc.) do you find most helpful in managing the acute symptoms of PUD?
A meta-analysis of studies indicates that overall healing rates for duodenal ulcers with sucralfate range from 60% to 90% at 4-6 weeks of treatment. This data confirms sucralfate's effectiveness for its primary approved indication. The data for gastric ulcers is more nuanced and somewhat contradicto...
What is your general approach to treating bleeding gastric masses with palliative RT?
We once had a patient with stage IV NHL who had transfusion-dependent bleeding from a pesky gastric mass that was chemo-resistant. It turned into a fatal complication, so it was presented as an educational case at ASTRO. We gave 4 Gy x 1 which stopped the bleeding within 24h, and switched to 3 Gy x ...
How long do you continue antibiotics after cholecystostomy tube placement for acute cholecystitis?
The solution to questions regarding treatment duration invariably falls under the category of "it depends." For individuals with severe illnesses, particularly those with bacteremia, an extended treatment period ranging from 7-14 days might be needed. Conversely, for patients who show significant im...
How would you approach the treatment of an SLE patient with refractory mucocutaneous ulcerations and lichenoid skin eruption despite treatment with MMF, Aza, Benlysta, Saphnelo, Rituximab, and JAK inhibitors?
This is an interesting case and the co-occurrence of SLE and Crohn's disease is rare but not unprecedented. The first issue is if the mucocutaneous lesions are related to SLE or the IBD and oral lesions are well described in Crohn's disease. Second, although cutaneous manifestations of Crohn's disea...
Is there a risk of hepatitis C activation with rituximab in a patient who has a history of HCV treated with antivirals and who is in sustained viral response?
In general, the risk of HCV flare with immunosuppression in general including rituximab must be viewed as minimal for those who have achieved a sustained virologic response (Undetectable HCV RNA ≥12 weeks after treatment completion) and does not influence my therapeutic decision-making if the patien...