Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
How do you approach the management of a patient with an ileostomy who has recurrent prerenal AKI episodes that improve with IV fluids but worsen with each attempt to transition to oral fluids alone?
This can be a difficult problem to deal with. In addition to electrolyte losses and volume depletion, these patients can have problems with caloric and micronutrient/vitamin depletion, so close collaboration with a nutritionist and gastroenterologist is important. Assuming the ileostomy can't be rev...
What would be your next line of treatment for disease control in a pediatric patient with metastatic hepatocellular carcinoma in partial response after multiple therapies?
Dear Dr. @Dr. First Last, Does the patient have an underlying hepatopathy (guessing yes, given the presence of varices)? And how old is the patient? Also - what was the AFP at diagnosis and what is it now? And what is the underlying liver function like? Final question - has the tumor been sequenced ...
Do you avoid terlipressin for patients with hepatorenal syndrome who have a serum sodium level less than 125 mEq/L?
This is a good question and I'll admit I don't have much first-hand experience using terlipressin. However, terlipressin is relatively (6X) selective for V1 vs V2 receptors and is used for its vasoconstrictor actions in HRS. Although there are reports (mostly retrospective and uncontrolled case seri...
How do you approach ongoing screening for TB in patients with a history of treated latent TB, but who have ongoing use of DMARDs and/or biologics given Quantiferon testing and PPD can remain positive?
Interferon-release assays (such as Quantiferon) and PPD testing do not discriminate between infection, reinfection, and prior infection with TB. However, in most developed countries, the likelihood that a patient who has once been treated for LTBI becomes reinfected and develops LTBI again is low, i...
How do you manage copper deficiency?
Copper supplements are available. Would need to exclude zinc excess as a cause and to discontinue zinc supplements.
How would you manage an elderly patient with type 3 achalasia who previously underwent POEM and has recurrent dysphagia, high Eckardt score, and dilated esophagus concerning for blown-out myotomy on esophagram?
This is a complex clinical scenario which requires a multi-disciplinary approach at an expert center. One of the main goals is to decipher why the patient is still having symptoms. Is the patient is having symptoms due to persistent achalasia or due to the blown out myotomy. You can make this distin...
When do you consider de-escalation from combination therapy with anti-TNFs and thiopurines to monotherapy with anti-TNFs in patients with IBD?
I withdraw the thiopurine if after 1 year the patient has achieved the goals of care.
Would you consider chemo-RT for duodenal adenocarcinoma s/p resection with at least 1 cm positive margin in a patient with a history of Crohn's disease?
I would not offer radiation in this scenario, especially if the patient has had multiple resections for Crohn's disease. There is no real data to guide adjuvant radiotherapy in duodenal cancer, but we borrow and extrapolate from other sites and rely on first principles to offer adjuvant treatment. H...
Would you transition a patient with axial spondyloarthritis to a biologic if their axial symptoms were controlled with an NSAID, but they also required a PPI to control dyspepsia/GERD caused by the NSAID?
If the axial symptoms are controlled, I would continue the NSAID and not switch to a biologic agent but I would refer the patient to a gastroenterologist for further evaluation and consideration of alternative treatments for GERD.
How will the findings from the recent BOSS study affect your management of Barrett's esophagus without dysplasia?
The findings of the BOSS study are consistent with emerging data suggesting that the risk associated with nondysplastic Barrett’s esophagus (NDBE) is lower than previously estimated and that routine surveillance may not meaningfully alter clinical outcomes. Compared to symptom-driven (“at-need”) end...