Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
In patients chronically treated for Wilson's disease with trientine hydrochloride (Syprine®), would you expect development of neurologic symptoms?
On trientine, patients with asymptomatic WD should remain asymptomatic. The onset of neurological symptoms in someone with only hepatic disease on maintenance therapy represents treatment failure. Precise rates and etiologies of treatment failure are lacking, though one cohort review documented 19% ...
How do you counsel patients about the malignancy risk associated with azathioprine?
Malignancy with the use of AZA (Imuran) was documented many decades ago in a renal transplant population, not in rheumatoid patients. Are they equivalent? Overall I consider Imuran a pretty safe DMARD. In fact, it can be used in pregnant patients with lupus, with mothers and babies doing just fine.
How would you treat a patient with metastatic cancer with a lesion invading the small bowel causing bleeding and potential obstruction?
Radiation reliably relieves bleeding but typically does not relieve obstruction. It may be worth trying if there is not an impending obstruction. We have plenty of experience in rectal cancer that this is a successful strategy. Since it's located in the small bowel, I would use standard fractionatio...
Would you be comfortable using a JAK inhibitor in a patient with baseline thrombocytosis?
Knowing the etiology of this patient's thrombocytosis is a critical piece of information required before determining whether a JAK- inhibitor drug could be safely prescribed. Mutations in JAK-2 are responsible for several myelodysplastic disorders, some of which present with thrombocytosis. Therefor...
What is your approach to pharmacologic treatment options in a patient with both SLE and Crohn's disease?
When someone has another systemic inflammatory disease along with SLE, I always look at the drugs that can treat both. I'd want close communication between myself and GI so they can guide me regarding the Crohn's severity and activity. If the Crohn's is moderate or worse in severity, we have azathio...
Does pregabalin contribute to esophagitis or gastroparesis?
Based on personal experience, no. Regarding gastroparesis, it appears that pregabalin is frequently used for the abdominal pain related to gastroparesis with acceptable results and without worsening of gastric motility: https://www.tandfonline.com/doi/full/10.2147/CEG.S362879
Which biologics are you comfortable combining with vedolizumab for spondyloarthritis or psoriatic arthritis patients in the setting of well-controlled inflammatory bowel disease?
Historically, rheumatologists have been hesitant to combine biologics in our patients, based largely on trials from 20 years ago that found an increased risk of serious infections when combining a TNF inhibitors and an IL1 inhibitor, or abatacept and another biologic. With the availability of newer ...
How do you manage GI side effects related to CFTR modulator therapy?
We have found that for most patients liver enzymes abnormalities are small and transient; however, for about 1% of patients there are severe elevations and these patients are much more difficult to manage, even after withdrawal, and tough to re-challenge; it is also not patients with severe liver di...
In a patient with recurrent fibrolamellar HCC a year after upfront resection (previously refused adjuvant therapy) with a solitary abdominal mass, would you offer neoadjuvant therapy to assess response?
Recurrent disease is the best care for under clinical trials for FLC. There are not many, sadly because of limited support. But there are some, like NCT03860272.
What is your approach to continuing or altering therapy when inheriting a patient with combined biologic immunosuppression that is in excess of guidelines?
This is by far the hardest task assigned for a practicing rheumatologist. Inheriting a patient on a regimen you did not develop and are uncomfortable continuing poses a daunting challenge: you are challenging the patient’s relationship with the previous rheumatologist, the control of the patient’s d...