Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
How often would you perform an upper endoscopy on an individual with chronic gastritis and previously eradicated H pylori with respect to risk of gastric malignancy?
Endoscopic surveillance of patients with chronic gastritis and previously eradicated Helicobacter pylori (H. pylori) would primarily hinge on endoscopic/histologic features on index endoscopy.Endoscopically and histologically, the presence and extent/distribution of gastric pre-neoplastic lesions no...
For palliation of gastric bleeding due to malignancy, is a G-tube a contraindication for RT?
I would not change my approach because of a G-tube and I base my dose/fractionation largely on performance status. This recent systematic review is helpful and highlights that a low BED regimen is typically adequate for effective palliation (Tey et al., PMID 28445941).
How would you manage a patient with Crohn's disease on a biologic and presents with non-bloody diarrhea, normal-appearing mucosa on sigmoidoscopy but severe colitis on biopsy with a positive CMV stain?
A few key pieces of information help distinguish CMV colitis from other competing diagnoses in this frequently encountered conundrum. An experienced pathologist will usually be able to tell you: If the CMV immunohistochemistry stain has good controls and whether it is floridly positive or scant. Al...
How would you manage active non-stricturing, non-fistulizing moderate ileal Crohn’s disease in patients on Natalizumab with well-managed multiple sclerosis?
I would be hesitant to add a second immunosuppressing medication to natalizumab. I might consider vedolizumab given a favorable safety profile (even though evidence suggests it is less effective for ileal disease) or talk with a Neurologist about switching from NAT to another drug for MS that might ...
Is prophylactic anticoagulation indicated in patients with frequent ulcerative colitis flares?
Background: We know that inflammatory bowel disease (IBD) is a risk for incident and recurrent venous thromboembolism (VTE). What is not clearly established is whether the IBD needs to be 'active' in order for it to be a risk factor, e.g. would patients who have had proctocolectomy (and perhaps no e...
Should platelet transfusions be considered for anti-platelet agent reversal in patients with major bleeding?
Patients on plavix and/or aspirin are at risk for bleeding whether in relation to surgery or bleeding from the gi tract. Much like the management of patients on anticoagulation temporary reversal of antiplatelet drugs is only achieved by normalizing platelet function. This is the same principle used...
How do you counsel patients with acute intermittent porphyria when it comes to fasting for religious reasons?
This is a very difficult question and it depends on the individual patient, their disease severity, their particular triggers, and how they have done in the past with caloric restriction. The patient may want to speak with a clergy member for guidance in this situation as well. For inst...
Do you usually recommend a modified diet for Clostridioides difficile infection (CDI)?
Post-infection IBS is common after C. diff infection, and some of these patients have dietary intolerances. Other than avoiding foods that exacerbate these symptoms, I do not recommend any particular diet. I also do not recommend probiotics, in keeping with society guidelines.
What is your approach to treatment of patients with fulminant C difficile infection who required ileostomy creation or colectomy?
Great question. If the entire colon has been removed, I do not see a role for oral vancomycin.
Is there a role for radiation in palliating malignant small bowel obstruction?
This problem has similarities to the management of symptomatic brain metastases. In both cases, cancer has caused a buildup of pressure in a vital organ. In both cases, it would be important to take non-radiotherapeutic measures (steroids in the case of brain mets, upstream decompression for SBO) to...