Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
How do you counsel patients on semaglutide or tirzepatide in light of potential cancer risks?
Use of GLP 1 RAs has sky-rocketed in recent years due to what seems to be a positive class effect on T2DM, weight loss, renal outcomes, cardiac outcomes and hepatic outcomes. I am not aware of any signals of increased malignancy risk. A brief literature review found meta-analyses showing possible be...
How do you manage copper deficiency?
Copper supplements are available. Would need to exclude zinc excess as a cause and to discontinue zinc supplements.
How would you manage an elderly patient with type 3 achalasia who previously underwent POEM and has recurrent dysphagia, high Eckardt score, and dilated esophagus concerning for blown-out myotomy on esophagram?
This is a complex clinical scenario which requires a multi-disciplinary approach at an expert center. One of the main goals is to decipher why the patient is still having symptoms. Is the patient is having symptoms due to persistent achalasia or due to the blown out myotomy. You can make this distin...
When do you consider de-escalation from combination therapy with anti-TNFs and thiopurines to monotherapy with anti-TNFs in patients with IBD?
I withdraw the thiopurine if after 1 year the patient has achieved the goals of care.
Would you consider chemo-RT for duodenal adenocarcinoma s/p resection with at least 1 cm positive margin in a patient with a history of Crohn's disease?
I would not offer radiation in this scenario, especially if the patient has had multiple resections for Crohn's disease. There is no real data to guide adjuvant radiotherapy in duodenal cancer, but we borrow and extrapolate from other sites and rely on first principles to offer adjuvant treatment. H...
Would you transition a patient with axial spondyloarthritis to a biologic if their axial symptoms were controlled with an NSAID, but they also required a PPI to control dyspepsia/GERD caused by the NSAID?
If the axial symptoms are controlled, I would continue the NSAID and not switch to a biologic agent but I would refer the patient to a gastroenterologist for further evaluation and consideration of alternative treatments for GERD.
Have you used oral vancomycin as prophylaxis for C difficile infection in patients admitted for allogeneic hematopoietic cell transplant?
Yes, but only in patients with a history of C difficile in the previous year and starting at the time of initiation of broad-spectrum antibiotics (e.g., for fever and neutropenia). We use 125 mg daily.We are aware this practice may be controversial. To my knowledge, there is only one randomized tria...
How will the findings from the recent BOSS study affect your management of Barrett's esophagus without dysplasia?
The findings of the BOSS study are consistent with emerging data suggesting that the risk associated with nondysplastic Barrett’s esophagus (NDBE) is lower than previously estimated and that routine surveillance may not meaningfully alter clinical outcomes. Compared to symptom-driven (“at-need”) end...
How would you manage a solitary unresectable liver metastasis?
Excellent question! Before starting any systemic treatments, has the patient undergone an MRI? Conducting an MRI prior to systemic therapy is crucial for accurately determining whether there are single or multiple liver metastases. The CAMINO study has shown that incorporating an MRI at the initial ...
In what scenario would you stack a patient on multiple laxatives (ex: Linzess + Prucalopride) if they have an incomplete response to single agent therapies?
This is a relatively common clinical scenario. Although there are no studies to support this approach—and likely never will be—I often combine a prokinetic agent, such as prucalopride, with a secretagogue in refractory cases of constipation. My preferred initial combination is prucalopride with plec...