Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
How do you approach managing depression symptoms in patients who have had repeated high risk of bleeding?
Overall, evidence suggests that while SSRIs do increase the risk of bleeding. The absolute risk of a bleeding event remains low and is usually not serious. A 2017 meta-analysis by Laporte et al., suggested that overall bleeding risk is increased by at least 36% while other meta-analyses suggest that...
When and how should we be stopping GLP-1 Receptor Agonist/Dual Agonist therapy?
I usually continue for 3-4 years, the tapering down slowly over 1 year period, buy then the set point for energy expenditure and appetite likely is changed.
When and how do you do testing for disaccharidases on GI biopsies?
You can send two biopsies from the 3rd portion of the duodenum for enzyme assays, but it might be easier just to do simple disaccharide absorption tests.
Do you prescribe respiratory muscle training (RMT) devices to patients with dysphagia?
We encounter dysphagia frequently in our patients with Parkinson's disease and other movement disorders. If there are any concerns about swallowing or aspiration, my first step is to refer to Speech Therapy for evaluation, and I defer to their expertise for specific treatments from there. That said,...
What is your approach to iron deficiency anemia after negative EGD and colonoscopy?
If there is no sign of atrophic gastritis and repeated fecal tests for blood are negative, I’d look first for celiac disease. If all the celiac screening tests rule it out, then I might team up with a hematologist to look for rare birds like transferrin deficiency. I’d probably ease back on PPIs if ...
How do you decide between anticoagulation and observation for an incidentally detected subsegmental pulmonary embolism in elderly patients with a history of gastrointestinal bleeding?
We face this conundrum not infrequently because subsegmental emboli are subject to high inter-reader variability, and the accuracy of the finding in isolation is suspect (Batayneh et al., Blood 2023). I once mentioned this to a radiologist who reads CTAs and was told, tactfully, that I was full of i...
What is your preferred first-line regimen to treat a severe or fulminant C difficile infection?
IV vancomycin and PO Flagyl are the easiest combination to get for a hospitalized patient. I’ve had much experience with this, and it works very well. IV vancomycin and PO Flagyl as initial treatments in the hospital is my preference. This is before I go onto stronger drugs, with those requiring al...
What factors make you consider an EUS before embarking on an ERCP for concern for type 1 Sphincter of Oddi dysfunction, (appropriate biliary symptoms, dilatation of ducts with no stones on MRCP, and liver labs suggestive of cholestasis)?
When clinical presentation is not typical for SOD and imaging raises the question of an anatomical/structural cause, or history of idiopathic recurrent pancreatitis, a diagnostic EUS may be helpful in this context. If the clinical presentation with LFTs and imaging meets criteria for type 1 SOD, EUS...
Do you recommend checking anti-drug antibodies for patients on TNF inhibitors?
This is a very good question with direct clinical practice implications. I do not check or follow anti-drug antibodies when using TNF inhibitors for the treatment of rheumatoid arthritis or psoriatic arthritis. There are reports that suggest, on a group level, that these antibodies, if present, impa...
When and how should we use biomarkers (i.e., CRP, stool calprotectin, mAb levels) to guide or optimize medical management of Crohn’s disease or ulcerative colitis?
The principal clinical applications of biomarkers in IBD are as follows: Assessment of severity and prognosis during a flareup. Monitoring the efficacy of treatment. Determining the probability of postoperative recurrence of Crohn’s disease (i.e., the high negative predictive value of FPC for anasto...