Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
Do you routinely give prophylactic antibiotics prior to ERCP for biliary obstruction in light of recent studies suggesting a reduction of periprocedural infection?
I did not use to give antibiotics routinely prior to ERCP, and it seemed post-ERCP antibiotics were given at the discretion of the advanced endoscopist, but the results of this meta-analysis will likely change my practice so that I'll give all patients a dose of Ceftriaxone prior to the procedure to...
What is your treatment approach to a patient with budesonide refractory microscopic colitis and multiple sclerosis?
First job is to be sure the colitis is not attributable to any medication, particularly ocrelizumab. Meanwhile, have you given an adequate trial of bismuth?
When can we consider deferring an insulin drip in patients with hypertriglyceridemia-induced pancreatitis?
Serum triglyceride levels >500 mg/dL (5.6 mmol/L) are required for hypertriglyceridemia to be considered the underlying etiology of acute pancreatitis (UpToDate).For patients with severe hypertriglyceridemic pancreatitis, such as those serum triglyceride levels >1000 mg/dL plus lipase >3 times the u...
What interventions do you find helpful for the initial management of functional GI disorders in primary care?
TCAs seem to help modulate pain, particularly at low doses.
Do you prefer formal testing to establish a diagnosis of SIBO/IMO over empiric treatment?
Great practical question. I prefer formal testing for several reasons: Even though postprandial bloating and distention along with change in bowel habits are the hallmarks of SIBO/IMO, they are non-specific and can be caused by myriad of other organic causes. A normal breath test would direct the a...
For patients with celiac disease confirmed on endoscopy with characteristic endoscopic findings, do you routinely repeat EGD to document healing, or just follow up with serial serologies and repeat EGD only based on the absence of clinical response?
If a patient has been able to effectively avoid gluten and there is no diarrhea, labs are normal, and tissue transglutaminase (TTG) is normal, there is no need for a follow-up endoscopy. Follow-up endoscopy is indicated if there is suspicion that villous atrophy continues.
How do you decide when to use acid-suppressive medications for GI prophylaxis when patients are on prolonged corticosteroid therapy?
We only use acid-suppressive medications for GI prophylaxis in patients treated with corticosteroids when they have additional risk factors for upper GI bleeding. Risk factors include concomitant NSAID or antiplatelet therapy, history of GI bleeding or peptic ulcer, age over 60 years, prednisone dos...
Can fatty liver disease present with elevations in alkaline phosphatase without other liver enzyme elevations (AST and ALT)?
It is very atypical but can occur. Patients usually have elevations in aminotransferases (usually ALT higher than AST) and there can be very mild concurrent elevations in alkaline phosphatase. An isolated alkaline phosphatase elevation should however prompt a more extensive serological work up as we...
In a young patient who was vaccinated to chickenpox as a child (no previous varicella infection) should the patient receive a shingles vaccine prior to starting Rinvoq?
Yes. The vaccines are different and current vaccine is to prevent zoster for patients who have been previously exposed to varicella or vaccinated for varicella.
How do you decide between anticoagulation and observation for an incidentally detected subsegmental pulmonary embolism in elderly patients with a history of gastrointestinal bleeding?
We face this conundrum not infrequently because subsegmental emboli are subject to high inter-reader variability, and the accuracy of the finding in isolation is suspect (Batayneh et al., Blood 2023). I once mentioned this to a radiologist who reads CTAs and was told, tactfully, that I was full of i...