Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
After confirming the patient is not on NSAIDs, how do you approach acute ileitis on biopsies in a patient without symptoms or with only mild loose stools?
Is diarrhea inflammatory? What is her level of calprotectin? A useful biomarker to follow. Aphthous ilieitis does not have risk features for progressive Crohn’s that, at least at this time, does not require an advanced agent. You can use symptomatic agents (loperamide, cholestyramine, etc.) to asses...
Do you routinely check Infliximab levels on day 3 with patients admitted with acute severe ulcerative colitis?
Conceptually, while this is an important concept, from a practical standpoint, most hospitals do not have a point-of-care IFX assay that can provide levels right away. Most IFX levels in the real world take around a week to come back, which makes that not impactful from a clinical standpoint in acut...
How do you approach HCC screening in patients with advanced fibrosis e.g., F3 on FibroScan?
We should first understand the underlying principles that defined the various cut-offs that resulted in this recommendation (eg, cost-effectiveness threshold for HCC screening, cut-offs for advanced fibrosis) and then go from there. Among patients with cirrhosis, the cost-effectiveness threshold wa...
In patients with EGJOO on esophageal manometry, how do you approach subsequent testing for further evaluation?
In order to make a clinically relevant and conclusive diagnosis of EGJOO, patients must not only have manometric findings of EGJOO but also clinically important/related symptoms and at least one additional test which shows evidence of obstruction at the EGJ. This additional testing is with either a ...
How do you approach a patient with endoscopic ileitis without typical features of chronicity on histology, who has worsening abdominal pain and increased stool frequency despite a trial of budesonide?
I am not sure, but I will assume "without typical features of chronicity" means it is either normal or acute inflammation. Acute inflammation is either prep effect, exogenous hormones, or NSAIDs, but this is not Crohn's and would be treated as IBS. If normal, then for sure treat as IBS.
What is your endoscopic approach towards laterally spreading colonic lesions that are over 2 cm in size?
Laterally spreading tumors or LSTs can be of the granular or non-granular type, and the former may have surface nodularity (LST-G-N) and the latter may have a depressed center with different risks of occult cancer and submucosal invasion. LSTs of the nongranular with pseudo-depressed (LST-NG-PD) mor...
What are the target distensibility index and EGJ diameter values on EndoFLIP following peroral endoscopic myotomy (POEM)?
An increase in the intraoperative EGJ-DI following POEM correlates with improved symptomatic response. Persistent DI < 2 is associated with poorer outcomes. When using EndoFlip, our team evaluates patients following POEM by using the 60 mL fill volume and aims for a DI of at least 2.8 and a diameter...
How do you counsel patients on the use of compounded weight loss medications?
It is a difficult question that is being asked more frequently, recently, because of the shortage of these drugs. I handle it the same way that I used to handle when patients asked about the use of herbs as food supplements. The important fact is that we don't know the reliability of these products....
Do you avoid terlipressin for patients with hepatorenal syndrome who have an elevated bilirubin level?
The CONFIRM trial excluded patients with Grade 3 acute on chronic liver failure (due to increased risk of pulmonary complications). There have also been concerns raised that using terlipressin on liver transplant candidates might improve their MELD score enough to jeopardize their spot on the waitin...
How do people approach non-HIV patients with hepatitis B, a negative Hepatitis B E antigen, normal LFTs and relatively low HBV DNA between 2000-20000?
Treatment of chronic Hep B is recommended to prevent maternal-fetal transmission, reactivation during chemotherapy, recurrence after liver transplantation, and in patients with decompensated cirrhosis. Treatment has been shown to reverse fibrosis and cirrhosis. Specifically referring to the above sc...