Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
How do you approach the use of fidaxomicin versus vancomycin for initial Clostridioides difficile infection in immunocompromised patients, considering the lower recurrence rates but higher cost of fidaxomicin?
Whether immunocompromised or not, fidaxomicin has been demonstrated to be superior to vancomycin – not in resolution of the acute infection but in reducing the risk or recurrence by approximately one-half. In one study of hospitalized patients published in 2015, it was reported that, when taking int...
After endoscopic control of variceal hemorrhage, what minimum safety bundle (timing, tube type/size, monitoring, and contraindications) do you require to place a small-bore nasoenteric tube within 24 hours for nutrition and hepatic encephalopathy therapy?
I usually wait at least 48 to 72 hours before placing a Dobhoff or Keofeed small-bore nasoenteric tube. This allows sufficient time for bands to create their local ulcers and then fall off, minimizing the risk of rehemorrhage.
How do you decide between anticoagulation or portal vein recanalization in a patient with portal vein thrombosis?
It depends on cirrhotic vs non-cirrhotic. For cirrhotic, best to reference the AASLD 2020 guidance here - Northup et al., PMID 33219529.For non-cirrhotic: important to determine the etiology as well as evaluate for a hypercoagulable state, including checking for JAK2 and CALR.If acute and non-occlus...
How do you decide whether to initiate semaglutide for MASH when alcohol intake is near MASLD/MetALD boundary ranges or fluctuates with intermittently positive PEth—specifically, do you require a documented period of reduction/abstinence before treatment, or do you start therapy with a modified monitoring/futility framework?
Typically, my approach is to ensure that alcohol is not contributing to their liver disease before initiating anti-fibrotic therapy. I usually counsel them and monitor their PETH testing serially. Sometimes, cutting out alcohol itself will help reduce their fibrosis level over time and may obviate t...
In suspected antibiotic-associated cholestatic DILI with jaundice and no obstructing lesion on MRCP, what specific clinical or laboratory trajectory triggers you to proceed to early liver biopsy to evaluate for evolving vanishing bile duct syndrome rather than continued close outpatient monitoring?
This is an important question because early awareness and a confirmed diagnosis will result in a better outcome. 1- Needs a clear history and exclusion of other potential etiologies. 2- Need to know whether the patient has underlying liver disease, i.e., metabolic dysfunction-associated steatotic li...
In patients entering AUD treatment who also have obesity/diabetes (a MetALD phenotype), how do you modify your thresholds for fibrosis assessment and for initiating AUD pharmacotherapy and metabolic therapy (e.g., GLP-1 receptor agonists) with the explicit goal of reducing future liver and cardiovascular events?
In patients with a MetALD phenotype entering AUD treatment, I do not lower fibrosis assessment thresholds but rather focus on the higher pre-test probability that they may have significant liver fibrosis; I apply standard guideline-based NIT cutoffs while ensuring timely and complete evaluation. I u...
How do you approach the workup for a patient with imaging showing features suggestive of cirrhosis?
It is important to clarify what features of the imaging are resulting in this diagnostic impression. Liver nodularity without other findings of cirrhosis is non-specific and does not make a diagnosis of cirrhosis. An incidental finding of a nodular liver with normal liver enzymes and normal platelet...
With the latest hepatitis B guidelines and recent phase 3 trial of Bepirovirsen mentioning the utility of quantifying HBsAg levels, how have you incorporated HBsAg in your practice?
Since the first New England journal publication on Bepi (Yuen et al., PMID 36346079), which demonstrated functional cure in patients with less than 1,000 international units of surface antigen, we’ve been quantifying surface antigen in all of our hepatitis B patients. Almost all the large commercial...
In patients with iron deficiency due to history of gastric bypass or IBD, would you consider oral iron therapy if the iron deficiency anemia is mild?
Oral iron can often be effective in iron deficiency, as long as absorption is intact. If you are concerned about absorption, performing an oral iron challenge can be useful in allowing you to avoid long trials of oral iron that will be ineffective. Simply check an iron panel at baseline, then admini...
Is there evidence that certain PPIs provide superior clinical efficacy compared to others in real-world practice?
While there are some differences between PPIs in terms of metabolism, bioavailability, and duration of acid suppression, generally speaking, in clinical practice, the efficacy of different PPIs is comparable. With that said, some differences include dexlansoprazole's dual-release nature which genera...