Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
How would you approach additional workup and management of a patient with active Crohn’s disease, who has multiple lung and brain nodules, with lung pathology demonstrating necrotizing granulomatous inflammation and brain biopsy with granulomatous inflammation and medium-large vessel vasculitis?
This is a great question and a challenging case. Further workup would depend on the clinical presentation and the risk factors of this particular patient, however, I will outline some broad considerations centered around questions I would consider in a similar case. Has Crohn's disease been definit...
Would you treat an unresectable MSI-H colon cancer patient with persistent hepatitis C with immunotherapy?
Great question.There are two questions here:Question 1. Should we treat an unresectable MSI-H colon cancer patient with immunotherapy? The answer is yes, based on the data we have from metastatic disease trials such as KEYNOTE-177 and CheckMate 142 studies. We can also use the phase 2 study data fro...
What is your treatment algorithm for management of retroperitoneal fibrosis that does not respond to high-dose glucocorticoids?
There are a number of caveats to this. Is the retroperitoneal fibrosis biopsy-proven and/or IgG4 disease ruled out? If a case is refractory, I first question whether the diagnosis is correct and will often biopsy in this situation with more than an FNA biopsy. The second question is how long have t...
How do you approach management of patients with active RA and recurrent non-severe C.diff?
I think the question here is why the patient is experiencing recurrent C.diff. Is it true recurrence or it never fully clears? Any IgA deficiency? CVID? I would do an immune deficiency work up- complements, immunoglobulines and flowcytometry, response to pneumococcal vaccine. In parallel to the wo...
In patients with HCC and asymptomatic but endoscopically visible varices, how long do you wait to start bevacizumab after banding?
That is an excellent question and one that does not have a clear answer to date. In these situations, timing of bevacizumab initiation depends on the patient's risk of bleeding and often is a discussion between oncology and a skilled endoscopist. We typically wait ~3-4 weeks after an intervention fo...
What is your approach to working up diarrhea in an immunocompromised patient?
Tough question and very common in clinical and research management. The approach is going to mirror any new complaint and start with a history. Diarrhea means many things to many patients/clinical trial subjects, so characterizing duration, frequency in a day, nocturnal events (diarrhea that occurs ...
Do you discontinue or adjust azathioprine when a patient develops elevated MCV after starting it?
Great question, with practical implications for the clinic: Azathioprine (AZA) is a prodrug that likely exerts its immunosuppressive effects against B- and T-cell function by interfering with purine metabolism through its metabolites (including 6-MP). Logically, many of the "classic" AZA side effect...
Would you recommend stent placement upfront in a patient with cervical esophageal cancer and a TE fistula?
Malignant TE fistula is a complex problem which is often associated with a poor prognosis. Palliation with stenting can be problematic as the stent can erode and make the fistula larger. This is especially problematic with "kissing" stents in both the esophagus and the airway and/or in the setting o...
Do you consider anti-viral prophylaxis in patients taking JAK inhibitors who have recurrent uncomplicated Zoster infection, but would prefer not changing therapy?
This is a really good question without a clear answer. Patients on JAK inhibitors are not only at increased risk for VZV but also for recurrence. Data from Kevin Winthrop and colleagues examining the tofacitinib database revealed that patients with RA and PSA are at 10 to 20 times increased risk for...
Has pelvic MRI replaced EUS as the standard of care for rectal cancer staging?
I think looking at data both show very similar sensitivity and specificity for staging and is matter of expertise and resources available at the institution.