Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
Is there a role for use of JAK inhibitors instead of corticosteroids to induce clinical remission in those with severe ulcerative colitis?
Tofacitinib and upadacitinib are specifically approved for the treatment of moderately to severely active ulcerative colitis (UC), and both had steroid-sparing endpoints in their clinical trial programs. However, so do many of our newer therapies for UC. Both agents have demonstrated efficacy within...
How would you approach the evaluation of a patient with decompensated cirrhosis, suspect to be due to alcohol, who is not a liver transplant candidate with iron studies showing elevated saturation and ferritin over 1000?
The finding of elevated iron saturation (I suspect means above 55%) and high ferritin raises the diagnosis of true iron overload. Certainly, a Ferritin level above 1000, when the patient is not actively drinking, is consistent with cirrhosis. So, I would start phlebotomies if the Hgb >11-12 g/dL all...
In patients with suspected disorders of gut-brain interaction, at what point do you consider evaluating for carbohydrate malabsorption syndromes, and which test do you get?
My approach is based in part on the North American Consensus on breath testing. This is affirmed by other international consensus statements as well. It is important to first rule out microbial overgrowth with a lactulose breath test before doing carbohydrate malabsorption breath testing. If microbi...
How do you approach an otherwise healthy patient with an incidental 1 mm GIST involving the serosal surface in terms of staging workup, EGD, and surveillance?
These incidental "micro-GISTs" are not likely to become a clinical problem. Interestingly, you describe a "serosal" lesion which would not get picked up on endoscopy anyway, but not unreasonable to check again in a year with a CT AP and EGD. I don't think we have any evidence to support continued lo...
Do you have a standard approach to using POCUS to evaluate acute abdominal pain?
I don't have a standard framework for evaluating acute abdominal pain because my approach as a hospitalist depends very much on the history and available data. This is usually very different from the ED context, though we not infrequently have patients develop acute abdominal pain during hospitaliza...
How would you approach the management of asymptomatic ALT and GGT elevation in an older adult patient with depression with psychosis and without history of hepatitis who recently had dose of quetiapine increased and new initiation of SNRI?
The answer when you suspect drug-induced liver injury depends on the X elevation above normal of ALT and bilirubin. In addition, exclusion of other coexistent factors, i.e., alcohol use, metabolic risks, or other medications. From liver tox, quetiapine may elevate liver tests in 30% of patients. Bel...
How do you approach the treatment of UC with PSC and how do you position oral vancomycin against biologic therapies?
A number of case reports have suggested that oral vancomycin improved the course of PSC, but more rigorous clinical trials have failed to confirm the benefits. [Deneau et al., PMID 32946600. Assis & Bowlus., PMID 37084929]The treatment of neither UC nor PSC seems to affect the other condition. That ...
How do you remove and code for the following polyps?
I would inject and remove with a hot snare. It also depends on the location of the polyp. If the polyp is in the cecum, I would use a cold snare. I would code this as EMR. I would inject and remove this one also in one piece if possible. I would code this as EMR.
In patients on long-term proton pump inhibitors for GERD with stable symptoms, do you routinely attempt discontinuation or continue indefinitely given relapse risk?
This is a good question, as we see many patients who were placed on PPIs and continued indefinitely for GERD. As this question implies, this may not be necessary, and long-term PPI use comes with risks that include C. diff. There are additional studies that suggest fractures, CKD, and nutrient defic...
How do you approach dosing beta blockers for variceal prophylaxis when the standard dose doesn’t achieve the target heart rate?"
The question is obsolete, actually, as the preferred beta-blocker for variceal prophylaxis is now carvedilol per AASLD guidelines as of 2024. Carvedilol is preferred given more optimal lowering of portal pressure as well as data supporting reduced risk of decompensation. Carvedilol is not titrated t...