Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
What treatments have you found most effective for cholestatic pruritus?
My experience is mainly in Sjogren's or Sjogren's with PBC, ursodiol has been effective. Occasionally, I have used hydroxyzine or H1+H2 blockers. In Sjogren's where the skin biopsy has shown significant lymphocytic infiltration, mycophenolate or a calcineurin inhibitor trial has lead to the resoluti...
How do you approach the treatment of microscopic colitis?
If there is a temporal association between starting a drug like NSAIDs, PPI, SSRI, statin in the onset of diarrhea deny would stop the medication before beginning pharmacological therapy for microscopic colitis. If there is no potential drug trigger, and I stratify my treatment based on severity of ...
How long should surgery be delayed in a patient with localized, resectable pancreatic cancer who developed acute pancreatitis following EUS guided biopsy?
This is a great question, and the answer is yes, it should be delayed to avoid surgical complications, healing, etc. In such scenarios, surgery might be delayed up to 2 months or longer even, depending on the time to recovery. In our practice, we employ a neoadjuvant approach for these patients and ...
How do you approach GI prophylaxis (e.g., PPIs, H2 blockers) in patients on long-term NSAIDs?
Risk analysis is at the heart of all therapies that we prescribe for our patients. Patients on long-term daily NSAIDS are at higher risk for GI symptoms, bleeding, and perforations. These risks can be between 2-4%/per year, and vary based on risk factors such as age, general health, cigarettes, prop...
Does hepatitis B vaccination reduce the risk of HBV reactivation associated with immunosuppressive therapy?
Hepatitis B reactivation is a critical concern when patients are undergoing immunosuppressive therapy, often described as 'deadly but preventable.' Screening for HBV is strongly advised before initiating biologic therapies, targeted synthetic therapies, or high-dose immunosuppression, including HBsA...
Do you have concerns with the use of oral contraceptives in patients on JAK inhibitors given the black box warning for thromboembolic events?
I would be concerned with the use of estrogen-containing OC especially in patients who are smokers, obese, and/or with a strong family history of CV disease. However, I know many rheumatologists who would still cautiously prescribe JAK inhibitors to these patients, particularly in the absence of add...
How would you approach asymptomatic hepatic sarcoid?
Hepatic involvement in sarcoidosis is very common. In old autopsy series, as many as 70% of unselected cases of sarcoidosis were found to have granulomatous inflammation in the liver. Today, many possible cases are identified incidentally by more advanced diagnostic testing techniques such as PET sc...
Do you recommend probiotics to patients receiving pelvic radiotherapy?
I have not routinely recommended a probiotic to patients receiving abdominal or pelvic radiation but I did learn early on in my career to suggest it if they continued to have symptoms beyond the usual 2 weeks following radiation and found that it often helped a great deal. I have no idea which is th...
How would you approach management of a patient with a medium-to-large vessel vasculitis who developed perforation of the stomach and colon on steroids and cyclophosphamide?
The answer to this question is complex as will depend on the most likely option for the etiology of the perforation and the nature of the underlying vasculitis. If the perforation is felt to be because of vasculitic activity then the decision could be whether to continue the current therapy (not eno...
Do you have a preference between Quantiferon Gold and T-spot TB for screening in patients starting immunosuppressive agents?
TSpot testing has better performance than Quantiferon Gold in patients with low lymphocyte levels, and/or on glucocorticoids (especially moderate to high doses). This is partially related to the way the essay is performed, and as such the Tspot is much less likely to result in an indeterminate or fa...