Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
What is your endoscopic approach towards laterally spreading colonic lesions that are over 2 cm in size?
Laterally spreading tumors or LSTs can be of the granular or non-granular type, and the former may have surface nodularity (LST-G-N) and the latter may have a depressed center with different risks of occult cancer and submucosal invasion. LSTs of the nongranular with pseudo-depressed (LST-NG-PD) mor...
How do you approach surveillance and repeat biopsies in a patient with a diagnosis of intestinal metaplasia (aka Barrett's esophagus) on pathology who appears to have a regular Z-line or <1 cm of salmon mucosa?
I agree with the other responses to this question. One other aspect that can be tricky in patients where you did not do the index endoscopy is that many patients present with the expectation that they will need further surveillance, or have already been told that they will need surveillance at some ...
What are the target distensibility index and EGJ diameter values on EndoFLIP following peroral endoscopic myotomy (POEM)?
An increase in the intraoperative EGJ-DI following POEM correlates with improved symptomatic response. Persistent DI < 2 is associated with poorer outcomes. When using EndoFlip, our team evaluates patients following POEM by using the 60 mL fill volume and aims for a DI of at least 2.8 and a diameter...
Should asymptomatic esophageal candidiasis identified incidentally on endoscopy be treated?
Yes, in our practice, we do treat asymptomatic esophageal candidiasis when found incidentally on endoscopy. A few things to consider: 1) While patients may be asymptomatic at the time of the endoscopy, untreated disease can lead to the future development of complications/symptoms, such as odynophagi...
What is your approach to perioperative risk stratification and optimization in patients with cirrhosis?
The VOCAL-Penn score is one piece of information that I use for risk stratification in patients with cirrhosis. I usually treat symptomatic decompensated cirrhosis first (hepatic encephalopathy, ascites, hepatic hydrothorax, hepatorenal syndrome, variceal bleeding), because the risk scores usually c...
Do you take any special considerations for a patient with ESKD who has an ileostomy/colostomy and wishes to start peritoneal dialysis?
My special considerations are to probably avoid PD. But it depends on what the surgical history was for that ileostomy or colostomy, e.g., there may be a lot of scar tissue. When PD works (flows easily in and out), it works; when it doesn',t it doesn't and if doesn't it usually doesn't get better (4...
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...
Do you routinely perform serologic testing for systemic sclerosis when absent contractility is identified on high-resolution manometry?
This is a good question. The first thing to consider is the LES pressure. If a patient has elevated LES relaxation pressure on high-resolution esophageal manometry, in combination with absent contractility, then this would be concerning for achalasia type 1 (especially when a patient also has delaye...
How do you counsel patients on the use of compounded weight loss medications?
It is a difficult question that is being asked more frequently, recently, because of the shortage of these drugs. I handle it the same way that I used to handle when patients asked about the use of herbs as food supplements. The important fact is that we don't know the reliability of these products....
How do you decide between systemic vs. arterially directed therapies in the first line setting for unresectable HCC?
In IMbrave150, 63% of patients treated with atezolizumab/bevacizumab had extrahepatic spread of disease, and my recommendation for patients with extrahepatic involvement is for first line systemic therapy. For patients with unresectable disease without extrahepatic spread, we take a multi-disciplina...