Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
Would you consider long term avatrombopag use in patients with cirrhosis requiring higher platelet counts for medical therapy?
In general, no, I would not use long-term avatrombopag in patients with cirrhosis requiring higher platelet counts for medical therapy due to the perceived thrombotic risk and hemostatic abnormalities of patients with liver disease.One thing to note in assessing the risk of long-term TPO mimetic the...
How do you manage fatty liver disease in patients on olanzapine who are reluctant to change meds?
I wonder if there are hepatologists available to consult with?There is a new drug with a novel mechanism of action Rezdiffra (resmetirom) that is specifically studied/designed for MASH (NASH). I haven't seen it used yet in my patients, but I am fascinated by the mechanism of action. Will it have psy...
Would you offer chemoRT to a colon cancer case with a resected polyp with positive margins if the patient wishes to avoid surgery?
“Wishes to avoid surgery” is different than refusing surgery. Subtle difference perhaps, but I feel like with proper counseling and persuasion, it is possible to “adjust” a wish. A hard refusal is a different matter. But be it wish or refusal, I would not irradiate. Think of how much normal tissue y...
Do you stop TNF inhibitors during the third trimester of pregnancy?
TNF inhibitor use in pregnancy is a common topic I review with patients. I make sure I include family members in my medication safety talks as well as provide tangible information, because unfortunately in the US there is a harmful stereotype that medications taken in pregnancy are bad and pregnant ...
What is your approach to managing ILD associated with inflammatory bowel disease?
We must first convince ourselves that the "ILD" relates to the underlying IBD. Patients may be on an immunomodulating regimen that increases the risk of opportunistic infections. The regimen itself may cause diffuse pneumonitis. Environmental/occupational exposures may also play a role. Armed with c...
How would you manage a patient taking a GLP-1 agonist for weight loss who continues to have symptoms (i.e., nausea, vomiting) related to reduced GI motility despite dose adjustments?
Anecdotally, I’ve had good success using prucalopride at twice-daily dosing (0.5 mg BID or 1 mg BID) in select patients. In my experience, tirzepatide tends to be better tolerated than semaglutide from a gastrointestinal perspective.
How would you manage autoimmune pancreatitis in a patient after Whipple's procedure?
There are two types of autoimmune pancreatitis (AIP): type 1 AIP, which is synonymous with IgG4-related disease (IgG4-RD) involving the pancreas and makes up a large majority of AIP cases, and type 2 AIP, which is largely associated with inflammatory bowel disease. I am assuming from the question th...
Do you discharge patients on preventative therapies like octreotide or bevacizumab after a patient's first admission for symptomatic anemia secondary to bleeding from a small bowel AVM that was treated with APC?
Not cost effective
What adjunctive therapies beyond an antisecretory agent (e.g., PPI, H2RA, etc.) do you find most helpful in managing the acute symptoms of PUD?
A meta-analysis of studies indicates that overall healing rates for duodenal ulcers with sucralfate range from 60% to 90% at 4-6 weeks of treatment. This data confirms sucralfate's effectiveness for its primary approved indication. The data for gastric ulcers is more nuanced and somewhat contradicto...
What is your general approach to treating bleeding gastric masses with palliative RT?
We once had a patient with stage IV NHL who had transfusion-dependent bleeding from a pesky gastric mass that was chemo-resistant. It turned into a fatal complication, so it was presented as an educational case at ASTRO. We gave 4 Gy x 1 which stopped the bleeding within 24h, and switched to 3 Gy x ...