Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
What are your go-to medical management options for high ileostomy output in patients with >100 cm of remaining small bowel?
First of all, you have to make sure that the patient's liquid intake is not composed of free water but an electrolyte solution at least 50% of the time. Metamucil at night Nana flakes in a milkshake at night Medication stepwise: Maximize loperamide Add diphenoxylate Add a PPI to reduce acid secre...
Where do SIBO testing and/or empiric antibiotics fit into the management of patients with bloating, abdominal pain, diarrhea, constipation, or distention?
There are now consensus papers on breath testing from North America, Europe, Asia (and Australia), Brazil, and, most recently, Argentina. All state that SIBO testing is important in the management of these functional symptoms. We have shown that methane is a cause of constipation, and Hydrogen on br...
For patients with HCC that have stable disease on immunotherapy alone, would you consider adding bevacizumab at the time of disease progression and continue immunotherapy?
Given we now have multiple options for treatment of HCC in the second line setting, at present, I would favor transition to a TKI or ramucirumab. If the patient had prolonged stable disease on single-agent immunotherapy and could potentially tolerate ipilimumab/ nivolumab, I would consider this regi...
If an IBD patient has only partial clinical response to a new biologic and or small molecule, do you extend the loading phase before transitioning to the maintenance dose/interval? How do you navigate insurance coverage?
As long as the patient is continuing to improve, I try to continue “induction dosing” before transitioning to maintenance dosing. This is particularly true for upatacitinib. We register all our patients with the Pharma companies' patient assistance (bridge) programs to circumvent insurance companies...
What new or emerging therapies for autoimmune gastritis are available beyond iron and vitamin B12 replacement?
Though we recognize autoimmune gastritis (AIG) as an autoimmune disease that targets antigens expressed on parietal cells of the stomach, there are currently no effective treatments to reduce gastric inflammation and to prevent parietal cell loss. Back in the 1960s, small studies looked at the role ...
How would you approach the consideration of continuing or ceasing colonoscopy for colon cancer screening in a relatively fit man in his 80s without a history of polyps on prior colonoscopies?
For someone in his 80s who has received good screening and never had polyps, continuing colonoscopy brings little benefit. The risks and difficulties from the procedure become greater with age, so, for most older adults, stopping routine screening is usually the better option for geriatric care. Whe...
How would you approach the management of asymptomatic ALT and GGT elevation in an older adult patient with depression with psychosis and without history of hepatitis who recently had dose of quetiapine increased and new initiation of SNRI?
The answer when you suspect drug-induced liver injury depends on the X elevation above normal of ALT and bilirubin. In addition, exclusion of other coexistent factors, i.e., alcohol use, metabolic risks, or other medications. From liver tox, quetiapine may elevate liver tests in 30% of patients. Bel...
How do you further workup and treat a patient with nausea and weight loss found to have granulomatous gastritis on endoscopic biopsies with a negative workup for sarcoidosis or Crohn's disease?
Its a good question and challenging scenario. It would be helpful to know a few more details. What was the endoscopic appearance of the stomach, and what symptoms triggered the work up - just nausea and weight loss? How much was the weight loss? How thorough was the work up for Crohn's disease? I as...
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.
How do you manage a patient with dysphagia whose EGD shows mild esophageal rings and furrows, but histology was negative for interepithelial eosinophils?
That is a great question. The question stem gives the impression that the endoscopic appearance is suggestive of eosinophilic esophagitis. A few things to consider: First, I would make sure that the procedure was done off any treatment, especially PPI therapy. Many patients come for endoscopy alread...