Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
What factors do you consider when a patient with acute severe ulcerative colitis flare responds to inpatient Infliximab, and you are deciding whether to switch to subcutaneous or continue IV maintenance dosing of Infliximab?
Patients admitted with acute severe ulcerative colitis typically have higher drug clearance related to significant fecal loss of infliximab through a highly inflamed colon, leading to low levels and often the need for dose escalation. There have been studies showing that infliximab levels in severe ...
Would you consider Resmetirom in a patient with metabolic risk factors and persistently elevated transaminases despite lifestyle changes, after a negative workup for other liver diseases, with noninvasive testing suggesting minimal fibrosis (F0–F1)?
Resmetirom is only approved for MASH with F2-3 fibrosis, so it will likely not get approved. If there is evidence of continued hepatic steatosis and no other competing etiologies, would continue current lifestyle recommendations and repeat fibroscan, ELF, or MRE in 1 year. If competing etiologies (e...
What is your treatment algorithm for solitary hepatocellular carcinoma, 3-5 cm, non-operative candidate but Child-Turcotte Pugh A/B?
This really boils down to two issues: CTP score and size of the lesion. For patients who are CTPA with a lesion <3 cm, RFA/MWA or SBRT are good options although there is some data from the University of Michigan (Wahl et al., JCO 2014) that lesions > 2 cm are better served with SBRT. For solitary le...
What is your approach to liver transplantation candidacy in those with decompensated cirrhosis who have been treated for a solid-organ malignancy, such as oral SCC?
This is an important consideration as patients who receive a solid organ transplantation will be on significant immunosuppression, which can result in significant proliferation of an underlying malignancy and have worse treatment outcomes compared to non-immunosuppressed patients. Furthermore, patie...
How would you approach the management of an incidentally detected subcentimeter nodule located just below/adjacent to the GE junction in a patient without Barrett’s, that is found to harbor high-grade dysplasia (HGD) on pathology following EMR?
I think this depends on the pathology and whether margins were clearly negative. If there is HGD on the margin, I think pt would need further resection, likely ESD, to ensure no dysplastic tissue remains. In addition, careful inspection of the esophagus and stomach under HD-WLI, as well as NBI or BL...
How would you resect an 11mm sessile gastric polyp?
I would first study the surface morphology and pit pattern. Specifically look for central depression or ulceration and signs of early cancer (such as Irregular or amorphous pit pattern). If central depression or irregular or amorphous pit pattern is present, I would consider en bloc resection with E...
How do you manage persistent rectal bleeding in the setting of rectal adenocarcinoma in a treatment-naive patient?
For a locally advanced rectal adenocarcinoma in the era of TNT, treatment of the tumor with either chemoradiation or chemotherapy upfront is reasonable, and both choices are known to palliate colorectal cancers effectively. With more severe bleeding, we often consider starting with chemoradiation th...
What are your next steps for a patient with gastritis on histology without NSAID use and H. pylori negative?
Gastritis is often reported on histopathology, but without more specifics from the pathologist, it has limited clinical utility. In my experience, qualifying the pattern and extent of gastritis can provide more guidance on subsequent management. The endoscopist should assess and document the visual ...
How long do you treat an isolated bacterial liver abscess which has either undergone percutaneous drainage or for which an indwelling drain is placed?
Until it's gone... Percutaneous drainage of liver abscesses is, in my experience, less effective than drainage of intra-abdominal abscesses, which isn't very effective. Neither type of abscess isn't, as I explain to other doctors and pts, a water balloon. Liver abscesses are more complicated than ot...
How do you choose between resmetirom and semaglutide in the treatment of MASH?
I write a disclaimer to start, because use of resmetirom ($5,000 per month) and semaglutide ($1,600 per month) at this time cannot be used across the board with any patient with hepatic steatosis. It's important to highlight how we characterize a patient's metabolic dysfunction associated steatotic ...