Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
When do you consider de-escalation from combination therapy with anti-TNFs and thiopurines to monotherapy with anti-TNFs in patients with IBD?
I withdraw the thiopurine if after 1 year the patient has achieved the goals of care.
Would you consider chemo-RT for duodenal adenocarcinoma s/p resection with at least 1 cm positive margin in a patient with a history of Crohn's disease?
I would not offer radiation in this scenario, especially if the patient has had multiple resections for Crohn's disease. There is no real data to guide adjuvant radiotherapy in duodenal cancer, but we borrow and extrapolate from other sites and rely on first principles to offer adjuvant treatment. H...
Would you transition a patient with axial spondyloarthritis to a biologic if their axial symptoms were controlled with an NSAID, but they also required a PPI to control dyspepsia/GERD caused by the NSAID?
If the axial symptoms are controlled, I would continue the NSAID and not switch to a biologic agent but I would refer the patient to a gastroenterologist for further evaluation and consideration of alternative treatments for GERD.
How will the findings from the recent BOSS study affect your management of Barrett's esophagus without dysplasia?
The findings of the BOSS study are consistent with emerging data suggesting that the risk associated with nondysplastic Barrett’s esophagus (NDBE) is lower than previously estimated and that routine surveillance may not meaningfully alter clinical outcomes. Compared to symptom-driven (“at-need”) end...
How would you manage a solitary unresectable liver metastasis?
Excellent question! Before starting any systemic treatments, has the patient undergone an MRI? Conducting an MRI prior to systemic therapy is crucial for accurately determining whether there are single or multiple liver metastases. The CAMINO study has shown that incorporating an MRI at the initial ...
In what scenario would you stack a patient on multiple laxatives (ex: Linzess + Prucalopride) if they have an incomplete response to single agent therapies?
This is a relatively common clinical scenario. Although there are no studies to support this approach—and likely never will be—I often combine a prokinetic agent, such as prucalopride, with a secretagogue in refractory cases of constipation. My preferred initial combination is prucalopride with plec...
Would you consider long term avatrombopag use in patients with cirrhosis requiring higher platelet counts for medical therapy?
In general, no, I would not use long-term avatrombopag in patients with cirrhosis requiring higher platelet counts for medical therapy due to the perceived thrombotic risk and hemostatic abnormalities of patients with liver disease.One thing to note in assessing the risk of long-term TPO mimetic the...
How do you manage fatty liver disease in patients on olanzapine who are reluctant to change meds?
I wonder if there are hepatologists available to consult with?There is a new drug with a novel mechanism of action Rezdiffra (resmetirom) that is specifically studied/designed for MASH (NASH). I haven't seen it used yet in my patients, but I am fascinated by the mechanism of action. Will it have psy...
Would you offer chemoRT to a colon cancer case with a resected polyp with positive margins if the patient wishes to avoid surgery?
“Wishes to avoid surgery” is different than refusing surgery. Subtle difference perhaps, but I feel like with proper counseling and persuasion, it is possible to “adjust” a wish. A hard refusal is a different matter. But be it wish or refusal, I would not irradiate. Think of how much normal tissue y...
Do you stop TNF inhibitors during the third trimester of pregnancy?
TNF inhibitor use in pregnancy is a common topic I review with patients. I make sure I include family members in my medication safety talks as well as provide tangible information, because unfortunately in the US there is a harmful stereotype that medications taken in pregnancy are bad and pregnant ...