Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
How do you explain the use of an AI scribe to patients the first time it is used in their care?
I use an AI scribe in my outpatient clinic, and around 90–95% of my patients agree to it. I obtain consent at the start of each visit and make it clear that it's completely optional—that they can say no at the start or change their mind at any point in the visit, with no impact on their care. I also...
How do you distinguish cannabinoid hyperemesis syndrome from cyclic vomiting syndrome?
When you are seeing a patient with intractable vomiting, this is a good time to slow down and take a thorough history. Often, patients can provide key pieces of information that help you distinguish cannabinoid hyperemesis syndrome (CHS) from cyclic vomiting syndrome (CVS). CHS typically occurs in y...
For a renal transplant patient on chronic immunosuppression with resolved esophageal symptoms (epigastric pain and intermittent dysphagia), does the presence of minimal CMV-positive cells on esophageal biopsy warrant preemptive antiviral therapy, or is clinical monitoring sufficient?
All things equal, in the average patient, if a patient has rare/minimal CMV-positive cells, it could occasionally represent a minimal infection or an incidental finding. However, in a transplant patient who is on immunosuppression, and especially one who has had recent symptoms (such as dysphagia in...
How do you select patients for ustekinumab optimization instead of switching therapy after secondary loss of response in Crohn's disease?
Optimizing a therapy before switching is likely a good idea because of the time that it takes for a prior authorization for another therapy. Drug levels for ustekinumab are available, so optimizing is possible. Having said that, the targeted anti-interleukins appear to be superior. So if a patient l...
Is there a role for use of GLP1 R agonist or dual agonist therapy for management of post bariatric hypoglycemia and dumping syndrome?
There is little systematically collected information in this area on which to base judgments. A case series of 5 post-bariatric surgical patients treated empirically with liraglutide described reduction of hypoglycemic events based on patient history. In an experimental study comparing several treat...
When do you consider de-escalating therapy such as dupilumab in eosinophilic esophagitis?
It is first important to recognize that EoE is a chronic condition. In a patient whose EoE is successfully being treated (whether it be with PPI therapy, swallowed steroids, food elimination, or dupilumab), the disease will invariably become active again over time if therapy is stopped. This is why ...
In a patient with low (or normal) BMI but findings of steatosis on imaging, no cardiometabolic comorbidities, and very elevated CAP scores, what are your next diagnostic and therapeutic steps to identify the cause of their steatosis and subsequent management?
In addition to knowing the level of steatosis, liver stiffness values would be of most interest. Alcohol use should stop if there is any level of fibrosis. Lifestyle modifications (dietary/exercise) should be part of recommendations, but with a goal of around 5 % weight loss. If they have F2-3 fibro...
In hospitalized patients treated for presumed overt hepatic encephalopathy who show no meaningful improvement after 48–72 hours of adequate therapy and precipitant management, what is your highest- yield next diagnostic step and what clinical features drive that prioritization?
At this point in the clinical care pathway, I would repeat an infectious workup (blood, urine, diagnostic paracentesis; occult infections are common in our cirrhotic patients) and perform a high-quality multiphasic cross-sectional imaging test to rule out hepatocellular carcinoma (HCC), portal vein ...
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?
Yes, this is applicable to patients who are on single agent immunotherapy, since the atezo/bev combination carries different mechanism of synergistic potential than single agent immunotherapy. Notably, currently approved second line agents are indicated after progression on sorafenib, however, curre...
How do you choose VOWST versus REBYOTA after an antibiotic course for recurrent C. difficile?
Just keep the patient on PO vanco 125 mg BID. That's plenty. Your GI tract would have to contain over 50 liters of fluid to dilute the vancomycin to a concentration below that of the C. difficile. Also, initial treatment should be longer than 10 days. I never understood the studies with a 10-day DOT...