Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
How do you manage a patient with Ogilvie's syndrome presenting with a cecal diameter above 12 cm unresponsive to conservative management with electrolyte correction, decompression by flexible sigmoidoscopy, and rectal tube placement?
While neostigmine has traditionally been used in this setting, it often faces pushback from both the hospital and pharmacy due to the need for cardiac monitoring. Additionally, it's not suitable for long-term use. Instead, I’ve been using pyridostigmine, which does not require cardiac monitoring and...
What are some helpful tips to identify and optimize visualization of the common bile duct on abdominal POCUS?
Good question! The common bile duct (CBD) can be difficult to visualize in general, but optimizing the gallbladder exam will also help to optimize the CBD. I am cautious about ruling out choledocholithiasis with POCUS, though a retrospective 2014 study showed that POCUS can be helpful in ruling out ...
How do you counsel cancer patients when they ask if they should avoid sugar?
“We don’t have evidence to support any specific diet that can either worsen or improve outcomes. I encourage a healthy, well-balanced diet with my top priority being you maintaining your weight during treatment.” Particularly for my head and neck patients, getting in sufficient calories is of the ut...
What clinical scenario do you consider screening for hepatitis delta?
I test every new patient with at least a Delta antibody. If patients have elevated ALT but low level HBV DNA levels, I will get a HDV RNA as my first test.
Do you recommend starting naltrexone at discharge for alcohol use disorder in patients with decompensated cirrhosis secondary to alcohol use?
Although naltrexone is generally safe to use in patients with cirrhosis, I would be cautious to use it in patients with decompensated cirrhosis, since it is mainly metabolized in the liver. I usually use acamprosate in patients with decompensated cirrhosis, with high bilirubin, as long as renal func...
What kind of monitoring do you choose in patients at risk for reactivation of hepatitis B who are on immunosuppression?
For patients at high risk of reactivation, I initiate prophylaxis and, given high efficacy, I don’t routinely monitor (other than to schedule annual appointments to make sure patients are getting refills). Generally, these patients are getting routine labs done by their oncologist or rheumatologist....
What factors into your choice to use craving-related medications (e.g., baclofen, naltrexone, acamprosate, etc.) in the management of alcohol use disorder?
When I discuss starting medications of alcohol use disorder (MAUD), we discuss reducing alcohol cravings, thereby reducing overall intake with the ultimate goal of abstinence with adjunctive psychotherapy if necessary. The options currently available in the market are naltrexone oral and intramuscul...
How do you incorporate other pharmacologic bariatric/appetite suppressants in the context of their clinical care plan for MASLD?
Patients with MASLD have different risk factors and drivers of disease (obesity, diabetes, eating disorders, etc). I lend personalized and individualized care when developing a care plan for patients with MASLD, including the risks, benefits, and alternatives to bariatric surgery (for those patients...
How does presence of clinically significant portal hypertension change patient prognosis in MASLD?
The presence of CSPH based on HVPG or the Baveno criteria (LSM on VCTE + platelet count) indicates higher chances of decompensation. Data from several clinical trials showed that higher VCTE LSM and lower platelet count are associated with higher annual decompensating event rates. Patients with MASH...
How would you manage long-segment Barrett's esophagus with both LGD and HGD that has failed to respond to RFA, cryoablation, or even Nissen fundoplication for large hiatal hernia?
ESD/multifocal EMR followed by may be a great option to assess T-stage/rule out occult esophageal cancer. However, the challenge with a large hiatal hernia is ongoing severe GERD and persistent esophagitis. This is a known risk factor for lack of response to endoscopic ablative and resection therapi...