Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
How would you treat a poorly controlled seronegative RA patient who is steroid dependent and is on azathioprine for autoimmune hepatitis?
I would add a biologic agent, likely a TNF inhibitor or abatacept. As with any patient with active RA, it would be important to add therapy that controls their disease activity, as well as allowing them to reduce or preferentially discontinue steroids. I would avoid other agents with known risk for ...
How would you approach new-onset large vessel vasculitis in a young patient with Crohn's disease?
Patients with Crohn's Disease (or IBD) can develop features of large vessel vasculitis or even other forms of vasculitis. The first consideration in a young patient would be determining the type of vasculitis--whether there is a distribution and clinical picture suggestive of TAK. It is important to...
How do you treat celiac disease associated inflammatory arthritis refractory to gluten free diet?
There is no good evidence based answer to this great question. In general, if celiac patients have persistent symptoms and exam findings of inflammatory arthritis or enthesitis, I offer non-biologic DMARDs depending on the severity of symptoms. If very mild, we can use hydroxychloroquine and escalat...
How would you approach a patient with imaging and labs suggestive of potentially resectable cholangiocarcinoma when several core biopsies reveal bridging fibrosis with no malignant cells?
I believe the first step would be presenting the patient's imaging and case at a multidisciplinary tumor board for input, especially from GI and surgical oncology, ideally at a higher volume center. You don't specify the route of prior biopsies but I am assuming they are percutaneous. Perhaps yield ...
When would you consider rituximab as induction therapy in IgG4-related disease?
This is a great question, especially given concerns around rituximab in the setting of the COVID-19 pandemic. I think it is reasonable to consider starting with steroids monotherapy for non-organ threatening diseases. Rituximab can be added if the patient relapses or if there is a concern for steroi...
When would you consider a workup for C. diff in a patient with diarrhea under-going concurrent chemoradiotherapy for rectal cancer?
Good question – and hard to pinpoint a strict answer. I think any time the diarrhea is out of proportion to expectation (i.e., very early in RT course), clinically significant (dehydration, etc), and not controlled or responding to anti-diarrheal medications, especially in the setting of C. diff ris...
How do you approach the continued use of TNF inhibitors in a patient with inflammatory arthritis who develops a positive dsDNA without clinical evidence of drug-induced lupus?
This is a good question and more common than we think. Most of us are not routinely drawing dsDNA ab when the patient does not have symptoms; some reviews suggest up to 29% (see review below). I have seen this, however, and continued medication with monitoring (following dsDNA ab levels with C3 and ...
How do you select systemic therapy for advanced HCC patients with portal vein thrombosis?
Generally, patients with advanced portal vein thrombosis (PVT) are excluded from studies, generally because it can impact the patient’s other hepatic indices. Extensive thrombosis may jeopardize blood flow in the liver, cause elevated bilirubin, reduced albumin, and increased ascites, i.e. lead to C...
How do you manage dyschezia and tenesmus following TNT with short course RT?
Specifically for the management of moderate to severe tenesmus and pelvic pain/cramping, I’ve found that combinations of steroids, bentyl, and gabapentin are very effective. Another consideration, if sequencing short course RT prior to chemotherapy, is to delay chemotherapy for 2-4 weeks after short...
Do you counsel patients with an ileostomy about significant diarrhea when treating the pelvis with radiotherapy?
For patients with an ileostomy, they should be told that they are expecting to have an ileostomy output of approximately 1 to 1.5 L per day immediately after recovery from surgery. However, the output may decrease over time.If a large amount of small bowel is in the pelvic radiation field and/or the...