Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
Do you continue antiplatelet/anticoagulant therapy in patients with hemodynamically stable diverticular bleeding to improve localization and treatment of source of bleeding?
Usually the decision to stop antiplatelet/anticoagulant therapy is dependent on the indication for starting the therapy, the severity of the bleeding and hemodynamic status of the patient. Based on the current ACG guidelines, it is ok to continue antiplatelet/anticoagulant therapy for hemodynamicall...
Do you recommend the use of SGLT2 inhibitors to reduce the risk of liver cirrhosis in patients with Type 2 diabetes mellitus?
Metabolic dysfunction-associated steatotic liver disease (MASLD) can be found in about 30% of adults in the U.S. Diabetes is a significant co-morbidity and increases the risk of progression to metabolic dysfunction-associated steatohepatitis (MASH). I calculate a FIB-4 index in these patients to see...
Is there a role for the use of transient elastography (FibroScan) to monitor liver fibrosis in patients on long term methotrexate?
Liver elastography is a useful tool to use when assessing the potential hepatotoxicity of various drug therapies. Traditionally, methotrexate accounted for nearly all the hepatotoxicity issues that we faced; however, we can add many other drugs to that list. Virtually, every immune suppressive drug ...
Which type of colonic polyps or mass-like lesions do you refer to an advanced endoscopist?
Generally speaking, endoscopists should remove all polyps that he or she can confidently remove as their skills and time schedule will allow. I would avoid sending polyps to an advanced endoscopist at a separate procedure simply because it would take longer or the lesion is in a "tough spot". On the...
What intervention would you choose for a patient with a post-bulbar NSAID-related diaphragm or stricture with a luminal diameter of 5–6 mm?
LAMS needs an advanced GI service to do it. Balloon dil has very limited results.
Do you switch to an alternative agent for C difficile colitis for a patient with suspected infection and positive testing who continues to have >3 watery bowel movements daily despite multiple days of oral vancomycin treatment?
The question about switching to another agent for Clostridioides difficile (Cdif) colitis in a patient who tests positive for Cdif but continues to have diarrhea despite multiple days of oral vancomycin treatment does not include any information regarding the clinical status of the patient, the pres...
How do you approach the management of a patient with an ileostomy who has recurrent prerenal AKI episodes that improve with IV fluids but worsen with each attempt to transition to oral fluids alone?
This can be a difficult problem to deal with. In addition to electrolyte losses and volume depletion, these patients can have problems with caloric and micronutrient/vitamin depletion, so close collaboration with a nutritionist and gastroenterologist is important. Assuming the ileostomy can't be rev...
What would be your next line of treatment for disease control in a pediatric patient with metastatic hepatocellular carcinoma in partial response after multiple therapies?
Gemcitabine (500 mg/m² IV) + oxaliplatin (50 mg/m² IV) every 2 weeks + lenvatinib 4 mg PO daily, or nivolumab (2 mg/kg IV) + gemcitabine (500 mg/m² IV) every 2 weeks + lenvatinib 4 mg PO daily.
Do you avoid terlipressin for patients with hepatorenal syndrome who have a serum sodium level less than 125 mEq/L?
This is a good question and I'll admit I don't have much first-hand experience using terlipressin. However, terlipressin is relatively (6X) selective for V1 vs V2 receptors and is used for its vasoconstrictor actions in HRS. Although there are reports (mostly retrospective and uncontrolled case seri...
How do you approach ongoing screening for TB in patients with a history of treated latent TB, but who have ongoing use of DMARDs and/or biologics given Quantiferon testing and PPD can remain positive?
Interferon-release assays (such as Quantiferon) and PPD testing do not discriminate between infection, reinfection, and prior infection with TB. However, in most developed countries, the likelihood that a patient who has once been treated for LTBI becomes reinfected and develops LTBI again is low, i...