Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
In patients with Met-ALD, would you still offer the same therapeutic/pharmacologic treatments (ex: GIP/GLP-1 agonists, Resmetirom, ex) for management of their disease as in a "pure" MASLD patient?
We would need to differentiate which is the bigger driver force (alcohol vs metabolic dysfunction) to determine the likelihood that MASH treatment would be effective. Alcohol use can be objectively quantified by phosphatidylethanol, which is a test commonly available in health systems with a liver t...
Given that cardiovascular disease is the top cause of morbidity/mortality in patients with MASLD, do you perform any additional screening and/or testing for these patients to minimize this impact?
MASLD should likely be thought of as part of a cardiometabolic disease with a wide spectrum of manifestations. I see my clinic as part of this management, but I do not do a complete cardiac assessment routinely on all my patients. I do not do this simply for the challenge of addressing all these iss...
Do you have any specific recommendations to prevent large fluctuations in sodium levels during a colonoscopy prep in patients with central diabetes insipidus on DDAVP?
Interesting, I have just received a message from a patient in this very same situation. I am not aware of any specific literature on this. In absence of such data, I usually recommend remaining on the same desmopressin dose and obeying to thirst, as I worry about hyponatremia that may be caused by a...
How do you approach the decision to repeat small-bowel biopsies in a patient with persistent gastrointestinal symptoms, like abdominal pain and diarrhea, when prior biopsies performed years earlier were normal?”
I typically do not repeat small bowel biopsies IF the symptoms have not changed in intensity or frequency. Repeat endoscopic evaluation and biopsies are done in patients with persistent GI symptoms if any changes have occurred: these may include significant worsening of symptoms, of symptoms occurri...
Do you routinely check vitamin K levels in post-bariatric surgery patients?
Vitamin K levels are not checked routinely in post-bariatric surgery patients. Deficiency of this vitamin is very uncommon in patients who have undergone a sleeve gastrectomy and even with Roux-en-Y gastric bypass. There is more potential for deficiency in patients who have had biliopancreatic diver...
What Barrett's Esophagus screening protocol do you follow for patients with scleroderma given the increased risk of reflux and esophageal stasis?
This is an excellent question and is probably also relevant to mixed connective tissue disorder (MCTD) and overlap syndromes. My answer is a poor one - to my knowledge, we just do not have the data to guide us. I would certainly be more vigilant, but do not have a set protocol other than that for BE...
What is the role of liver transplant in NET?
Identifying the role of liver transplant (txp) in NET patients with all the other therapy options available is challenging. I will admit that there have been several years since I last was involved in the care of a patient that actually ended up having a liver txp. That said, I think certain patient...
Is there a serum ammonium level for which you recommend initiation of dialysis in a patient with hepatic encephalopathy?
Because there is a very poor correlation between ammonia levels and hepatic encephalopathy, I do not make recommendations based on ammonia levels. My approach is to treat each case individually in consultation with our hepatology colleagues. If a patient has encephalopathy and is not responding to m...
What therapies would be considered safe and effective in pregnant patients with EoE?
Management of EoE during pregnancy should be individualized using a shared decision-making model. Food elimination can lead to remission, but some patients have difficulty following the diet. Proton pump inhibitors, such as omeprazole and esomeprazole, and swallowed budesonide are safe during pregna...
When managing patients with suspected MASLD, what specific criteria or findings would prompt you to refer them to hepatology?
In patients with suspected MASLD, I consider referral to hepatology when there is evidence of fibrosis by elastography or if I don't see improvements in related parameters with weight loss and/or medical therapies (GLP1-related meds, SGLT2i, TZDs).