Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
Is there a role for radiation in palliating malignant small bowel obstruction?
This problem has similarities to the management of symptomatic brain metastases. In both cases, cancer has caused a buildup of pressure in a vital organ. In both cases, it would be important to take non-radiotherapeutic measures (steroids in the case of brain mets, upstream decompression for SBO) to...
Is there a role for use of dupilumab for hypereosinophilic GI disorders distal to the esophagus?
No definitive studies performed yet and no FDA approval regarding using Dupilumab for EoG; however, in my opinion, I do believe that Dupilumab may be an effective treatment for some eosinophilic disorders beyond the esophagus.
Is there a role for anti-IL5 therapy in the treatment of EoE?
When looking at the use of IL-5 pathway drugs such as mepolizumab, reslizumab, and benralizumab in the treatment of eosinophilic esophagitis (EoE) studies to date have not demonstrated efficacy in terms of symptomatic improvement as related to the use of these series of medications. Each of these me...
Which patients with cirrhosis and portal hypertension are ideal candidates to undergo TIPS to reduce perioperative risk in anticipation of an elective surgery?
A pre-operatively placed TIPS may have a role in preventing hepatic decompensation and post-surgical complications in carefully selected patients undergoing elective abdominal surgery. The data to support TIPS pre-operatively is limited, given the varying surgical contexts and the generally poor pro...
How would you manage a patient with highly active ankylosing spondylitis, iritis and Crohn’s, controlled with weekly adalimumab with co-morbid IgG4RD and intolerance of azathioprine due to elevated LFTs?
There is not a known association between IgG4-RD and IBD or spondyloarthritis. Given that these are rare diseases, it is important to ensure diagnostic accuracy, as the combination of these diseases would be unusual, though not impossible. There are two types of autoimmune pancreatitis: type 1 (IgG4...
What is your treatment approach for a patient with metastatic hepatocellular carcinoma with Child's Pugh B cirrhosis?
Child Pugh B cirrhosis is a spectrum of disease, and requires careful consideration of the underlying cause of the cirrhosis as well as the potential impact of cancer therapy. As @Dr. First Last pointed out, there is data for sorafenib in this patient population, demonstrating a similar relative ben...
Should all patients diagnosed with B12 deficiency get a baseline EGD?
It is important to determine the cause of B12 deficiency. The majority of cases are due to pernicious anemia (atrophic gastritis and lack of intrinsic factor), I presume this question relates to that group. If there is another cause such as intestinal malabsorption or bacterial overgrowth, this does...
Would you intensify therapy in IgG4 related disease based solely on a persistently significantly elevated IgG4 level when all disease manifestations and inflammatory markers have normalized?
While a perfect biomarker does not exist in IgG4-related disease (IgG4-RD), patients who have elevated serum IgG4 concentrations at baseline typically demonstrate a significant reduction of IgG4 concentrations after treatment and with improved disease activity. In patients treated with rituximab, on...
What initial workup do you perform when there is a concern for porphyria?
This is a terrific question. But a broad question. Porphyria refers to a defect in heme biosynthesis leading to the accumulation of porphyrins and porphyrin precursors. We should remember that there are three general categories of porphyria based on clinical manifestations: acute hepatic porphyria (...
How do you monitor patients with incidentally found high titer anti-smooth muscle antibodies without stigmata of liver disease?
I have quite a few SLE patients with ASMA who do not have any signs of hepatic disease (though I did not do bxs in those with normal hepatic transaminases). They are very common in the general population. I have down in my notes a prevalence of 16%. However, there are studies showing prevalences as...