Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
Do you hold pelvic radiation for patient with clostridium difficile-associated diarrhea?
No. I proceed with radiation unless the diarrhea is not treatable with fluids and treat the C difficile with antibiotics. I am not aware of any data showing worsened toxicity of radiation concurrent with C difficile infection.
Are you routinely using thrombopoietin agonists in patients with hep C and HCC?
Thrombocytopenia is a common issue in patients with advanced liver disease due to decreased thrombopoietin production and hypersplenism sequestration from portal hypertension. The degree of thrombocytopenia is often a maker of both severity of liver disease.There are several TPO agonists on the mark...
Do you utilize EUS to determine the nodal radiation fields in esophageal adenocarcinoma?
Assuming that the primary lesion is PET avid, I would not hold up therapy for EUS. If the patient clearly needs to be treated for locally advanced disease, the only question is whether the fields need to be modified. EUS is better than CT (or PET CT) in determining the precise T-stage, especially fo...
Would you re-challenge patients who have had a TNF-associated paradoxical adverse event (such as inflammatory bowel disease) with a different TNF inhibitor?
I honestly have not heard of IBD as a paradoxical event with TNF inhibitors (unless possibly in a patient with underlying IBD that was not being treated adequately with etanercept rather than a monoclonal anti-TNF antibody). On the other hand, I have seen paradoxical psoriasis with TNF inhibitor use...
Is it okay to use COX-2 selective NSAIDs in patients with IBD-associated arthritis when the IBD is in remission?
I do not feel comfortable prescribing COX-2 NSAIDS to patients with IBD in remission. If I have such a patient and an NSAID is the major therapeutic option, I will reach out to the treating gastroenterologist for an opinion on whether this is advisable.
How do you manage patients who are Hepatitis B core antibody positive/surface antigen negative and starting a biologic DMARD (other than rituximab)?
According to the 2015 American College of Rheumatology Guidelines, a patient with natural immunity to Hepatitis B (Core & Surface Antibody-positive; Antigen-negative, normal liver function tests) can be treated as any other patient. However, monitoring of viral load is recommended "regularly" at 6-1...
How do you assess transaminitis in a patient with sarcoidosis with known liver involvement being treated with methotrexate?
This can be fairly tough, as you cannot assess for hepatoxicity from methotrexate in a patient who already has a transaminitis. Hepatic sarcoidosis occurs in 11-80% cases and is often asymptomatic. Some patients may have a transaminitis, elevated alk phos, or liver lesions noted on imaging. Serious ...
Do you avoid any specific biologic therapies in HIV positive patients?
At present, the most safety data on the use of biologics in HIV is TNF inhibitors. CD4 count should be > 200 and VL undetectable. Etanercept is most preferable, give lower incidence of serious infections as well as its efficacy as monotherapy (without methotrexate). Wangsiricharoen et al., PMID 2733...
How do you manage patients on atezolizumab/bevacizumab with advanced HCC who develop arterial thrombosis?
Arterial thrombosis such as coronary artery events or CVAs is an indication to discontinue bevacizumab. Patients with arterial thrombotic events within the past 6 months should not be treated with bevacizumab; events older than 6 months do not represent a contraindication, especially if the patient ...
For patients with HCC receiving atezo/bev, would you advise any other clinical investigations scheduled during treatment other than basic lab monitoring?
In the IMBrave 150 study, the most common serious toxicity in the AB arm was GI bleeding. And everyone was required to have their varices both evaluated and treated. It’s not convenient, but get the EGD before starting treatment!