Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
Would you start a biologic without a tissue diagnosis in a young male presenting with recurrent small bowel obstruction and MRE showing distal ileitis, which was unable to be reached despite repeat colonoscopy?
Thank you for your question. Not sure what “young” is, but in the differential are lymphoma and an inflamed Meckel’s diverticulum. You absolutely need tissue before you commit him to a biologic. Steroids can help with a lot of different things and should not be considered a diagnostic criterion for ...
In what scenario do you obtain ammonia levels in a patient with cirrhosis?
Very few people check ammonia levels now in patients with cirrhosis. It turns out that it’s not a really accurate measure, and it’s also difficult to draw and get to the laboratory. I think we need to use clinical judgment to diagnose encephalopathy and, of course, the opinion of close relatives.
How would you approach endoscopic diagnosis and treatment of an area of visible nodularity concerning for cancer within long segment Barrett’s esophagus?
I would begin by careful inspection of the Barrett's (BE) mucosa under HD-white light and narrow band imaging after washing off the surface mucus. I would evaluate the entire BE segment for nodules, ulcers, irregularities in pit-pattern and focal changes in vascular pattern, raising suspicion for in...
Would you pursue a colonoscopy for a patient in their 20s with constipation and rectal bleeding if they had a first-degree relative who died young from a "carcinoid tumor"?
Carcinoid tumor is relatively uncommon in someone who is relatively healthy and young. I would make sure to consider all the more common diagnoses and workup before considering carcinoid tumor. Moreover, carcinoid tumor is associated with diarrhea rather than constipation. Neuroendocrine tumor of th...
What is your preferred screening tool for colon cancer in an average-risk patient?
For their first time screening, I universally recommend a colonoscopy (in the absence of contraindications or social barriers) to evaluate for polyps, followed in 5-10 years by a yearly FIT or Cologuard every three years (unless the patient has a strong preference for a repeat colonoscopy). Repeat c...
How do you approach a patient with IgG4-related disease who has failed rituximab and mycophenolate and continues to rely on high-dose steroids?
Most cases of IgG4-RD respond to rituximab similar to the steroid treatment. When there is a lack of response to moderate dose steroid or rituximab, either the diagnosis is not IgG4-RD or the manifestation is not due to active IgG4-RD. In many cases, if treatment is delayed, fibrosis takes over the ...
How do you approach the treatment of Crohn's colitis in the setting of immunosuppression for liver transplant?
Good question, as additional immune suppression can increase the risk of infection. The anti-rejection drug mycophenolate can cause diarrhea, which could mimic a Crohn’s flare. I individualize Crohn’s therapy in a liver transplant patient. What type of Crohn’s do they have? What meds were they on pr...
How do you decide whether to place an NGT or PEG tube in patients with dysphagia precluding adequate PO nutritional intake?
There are several factors that go into the decision of PEG tube vs continued nutrition via a nasogastric feeding tube(NGT). Anticipated time to recovery of oral pharyngial function (especially in the most common underlying illness, which is stroke). NGT can stay in place for up to 2 months without...
What is your advice to patients with IBD who are on biologic therapies and planning for pregnancy?
Biologics are effective therapies for many autoimmune conditions, including IBD. The best outcome of a pregnancy is if a patient is in remission at the time of conception, which means she does not stop her therapy to get pregnant. Indeed, there are studies on women with nonspecific infertility who w...
Can rapid weight loss following GLP1 R agonist therapy lead to postprandial hypoglycemia and if so, what are the treatment options outside of dietary modifications?
This is a very interesting question but I am not sure that there is a clear published answer. Of course, we know that this class of medications can contribute to hypoglycemia in patients on insulin or SUs and in that situation the management would involve cutting back on the insulin or SU or decreas...