Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
Would you hold all immunosuppressive medications for the first month of LTBI treatment, or just biologics?
This video might answer your question: QD Clinic - Lessons from the clinic - Dx and Treating LTBI with a TNFI inhibitor features Dr. Jack Cush
Would you use an IL-17 inhibitor for a psoriatic arthritis patient with inactive inflammatory bowel disease?
It depends on the options. While I would generally avoid using an IL-17 inhibitor in a patient with a h/o IBD, if there are no other reasonable treatment alternatives, and the IBD has been inactive for a significant period of time (a year?), then I would consider it, after a full discussion of the r...
What is your preferred second line therapy for an HCC patient who progressed after first line checkpoint inhibitor monotherapy?
After progression on immunotherapy monotherapy, assuming the patient is still eligible for further therapy and VEGF inhibition, I will move to a VEGF TKI. While the data supports the use of lenvatinib or sorafenib in the front-line setting (REFLECT and SHARP trials), I will use one of these agents (...
Is there a role for regular hepatitis and TB screening in patients on chronic immunosuppressive therapy in the absence of new risk factors or exposures?
Unless there has been an interval introduction of new risk factor for TB or hepatitis B, there is no need to screen annually and baseline testing is adequate.
Would you recommend aspirin 600 mg daily for two years to a patient with Lynch syndrome and a history of colon cancer based on the results of the CAPP2 study for cancer prevention?
Yes, I would recommend this, with some caveats/considerations. 600 mg of aspirin daily x 2 years was the dose/duration shown to be effective in CAPP2--recently updated outcomes data from this trial (Lancet 2020) demonstrated an IRR of 0·50 (0·31–0·82; p=0·0057) for CRC among participants who were ab...
How do you approach screening for inflammatory bowel disease prior to starting IL-17 inhibitors?
IL-17i are now widely used to treat skin psoriasis (PsO), psoriatic arthritis (PsA), and axial spondyloarthritis (SpA). Genetic and epidemiologic studies suggest the coincidence of these diseases and Crohn’s diseases (CD) as they may present concomitantly in the same patient or affect a family membe...
How do you approach relapsed hepatocellular malignant neoplasm NOS after transplant in pediatric or AYA patients?
There exist no standards of care for patients with HCN NOS after front-line therapy has failed. Considerations include response to prior therapy, agents used front-line/not used, sites of disease, surgical options, and molecular findings of the tumor itself. Platinum/anthracycline-based therapy, car...
With what agents can you replace PPIs if they cause thrombocytopenia?
The incidence of PPI-induced thrombocytopenia is very low - and really only reported in case reports. I would suggest ensuring the low platelet count is really from the PPI (in some cases may be reasonable to re-challenge the patient), and not from a more common reason. In a recent case report on La...
How do you approach treatment of metastatic hepatocellular carcinoma in an adolescent?
Clarification - do you mean fibrolamellar carcinoma? Often mistakenly treated or referred to as a HCC variant or as a subset of HCC? Does it have the characteristic DNAj-PRKACA fusion for FLC? Is there underlying liver disease? Or do you mean conventional HCC? (common in older adults with liver dise...
Is there a role for liver transplantation in an initially unresectable HCC with a complete response after bevacizumab-atezolizumab?
I have had one patient who successfully underwent liver transplantation after an excellent response to atezolizumab plus bevacizumab. The patient was young and otherwise healthy. Further, he was taken off treatment and had no recurrence after 2-3 months off immunotherapy before being considered for ...