Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
Under what circumstances would you recommend early fecal microbiota transplantation over antibiotic treatment or bezlotoxumab in a patient with recurrent C. difficile infection?
Assuming donor stool is available, if the patient is not expected to need another course of antibiotics in the foreseeable future, I would recommend FMT.
How do you counsel cancer patients when they ask if they should avoid sugar?
“We don’t have evidence to support any specific diet that can either worsen or improve outcomes. I encourage a healthy, well-balanced diet with my top priority being you maintaining your weight during treatment.” Particularly for my head and neck patients, getting in sufficient calories is of the ut...
What clinical scenario do you consider screening for hepatitis delta?
I test every new patient with at least a Delta antibody. If patients have elevated ALT but low level HBV DNA levels, I will get a HDV RNA as my first test.
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?
I favor naltrexone over ease of use, especially if the patient has cravings. If the patient has anxiety that seems to be driving their alcohol use, I choose gabapentin 300 mg BID. If they don’t have anxiety or have a contraindication to naltrexone, I would go with acamprosate. If the patient doesn’t...
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).