Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
In a patient with well-controlled ulcerative colitis on tofacitinib for several years, would you consider switching to upadacitinib for a more favorable side effect profile?
If it aint broke, dont fix it! No difference in AE profiles between tofa and upa.
Is there a role for use of JAK inhibitors instead of corticosteroids to induce clinical remission in those with severe ulcerative colitis?
Tofacitinib and upadacitinib are specifically approved for the treatment of moderately to severely active ulcerative colitis (UC), and both had steroid-sparing endpoints in their clinical trial programs. However, so do many of our newer therapies for UC. Both agents have demonstrated efficacy within...
How would you approach the evaluation of a patient with decompensated cirrhosis, suspect to be due to alcohol, who is not a liver transplant candidate with iron studies showing elevated saturation and ferritin over 1000?
The finding of elevated iron saturation (I suspect means above 55%) and high ferritin raises the diagnosis of true iron overload. Certainly, a Ferritin level above 1000, when the patient is not actively drinking, is consistent with cirrhosis. So, I would start phlebotomies if the Hgb >11-12 g/dL all...
What is your approach to explaining the role of the microbiome to patients with inflammatory arthritis?
The gut microbiota play a central role in modulating the inflammatory response. This is especially relevant to inflammatory arthritis, where the pathogenesis is quite well understood, especially as it relates to arthritis associated with inflammatory bowel disease. We also know that the diet is the ...
In patients with suspected disorders of gut-brain interaction, at what point do you consider evaluating for carbohydrate malabsorption syndromes, and which test do you get?
My approach is based in part on the North American Consensus on breath testing. This is affirmed by other international consensus statements as well. It is important to first rule out microbial overgrowth with a lactulose breath test before doing carbohydrate malabsorption breath testing. If microbi...
How do you approach an otherwise healthy patient with an incidental 1 mm GIST involving the serosal surface in terms of staging workup, EGD, and surveillance?
These incidental "micro-GISTs" are not likely to become a clinical problem. Interestingly, you describe a "serosal" lesion which would not get picked up on endoscopy anyway, but not unreasonable to check again in a year with a CT AP and EGD. I don't think we have any evidence to support continued lo...
How do you approach the use of fidaxomicin versus vancomycin for initial Clostridioides difficile infection in immunocompromised patients, considering the lower recurrence rates but higher cost of fidaxomicin?
Whether immunocompromised or not, fidaxomicin has been demonstrated to be superior to vancomycin – not in resolution of the acute infection but in reducing the risk or recurrence by approximately one-half. In one study of hospitalized patients published in 2015, it was reported that, when taking int...
How do you decide between anticoagulation or portal vein recanalization in a patient with portal vein thrombosis?
It depends on cirrhotic vs non-cirrhotic. For cirrhotic, best to reference the AASLD 2020 guidance here - Northup et al., PMID 33219529.For non-cirrhotic: important to determine the etiology as well as evaluate for a hypercoagulable state, including checking for JAK2 and CALR.If acute and non-occlus...
Do you have a standard approach to using POCUS to evaluate acute abdominal pain?
I don't have a standard framework for evaluating acute abdominal pain because my approach as a hospitalist depends very much on the history and available data. This is usually very different from the ED context, though we not infrequently have patients develop acute abdominal pain during hospitaliza...
How would you approach the consideration of continuing or ceasing colonoscopy for colon cancer screening in a relatively fit man in his 80s without a history of polyps on prior colonoscopies?
For someone in his 80s who has received good screening and never had polyps, continuing colonoscopy brings little benefit. The risks and difficulties from the procedure become greater with age, so, for most older adults, stopping routine screening is usually the better option for geriatric care. Whe...