Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
When using vasoconstrictors for HRS-AKI, what MAP target do you use in practice (absolute MAP vs ΔMAP), and how do you adjust that target in patients with chronic hypertension, cirrhotic cardiomyopathy, or very low baseline MAP?
Aim for a mean arterial pressure (MAP) at least 10 mmHg higher than baseline when treating with norepinephrine. For terlipressin, it is not necessarily titrated to a MAP, but you will see an increase in MAP as a response.
How would you manage an asymptomatic patient after VCE showing small bowel Crohn's who passes the patency capsule but has retained the video capsule in the distal ileum with minimal surrounding inflammation?
A capsule can take up to 10 days to pass in a normal situation. If you have radiographic evidence of a retained capsule and the patient is on prednisone, it might take another 2 weeks or so to get the inflammation down. Remember that the capsule should continue to get crushed and really should pass ...
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 continue semiannual HCC surveillance after HBsAg loss in a non-cirrhotic patient with additional risk factors (e.g., first-degree family history of HCC and ongoing alcohol use), and what criteria drive that decision?
No
What is your approach to peri-operative 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...
In patients with GERD, when should Baclofen or alginate-based therapies be considered, and which patient characteristics warrant caution when using these treatments?
Baclofen and alginate-based therapies are adjunctive, phenotype-directed options for actionable GERD symptoms refractory to optimized proton pump inhibitor therapy. Baclofen reduces transient lower esophageal sphincter relaxations and is most effective in regurgitation or belching predominant phenot...
Are there any biomarkers that might indicate who might be responders to atezolizumab/bevacizumab for HCC?
Not at this time. Some preliminary studies are being done as ad hoc at this point and was not pre specified before the IMbrave study launching
For patients with HCC that have stable disease on immunotherapy alone, would you consider adding bevacizumab at the time of disease progression and continue immunotherapy?
Given we now have multiple options for treatment of HCC in the second line setting, at present, I would favor transition to a TKI or ramucirumab. If the patient had prolonged stable disease on single-agent immunotherapy and could potentially tolerate ipilimumab/ nivolumab, I would consider this regi...
Do you add elafibranor or seladelpar to UDCA within the first year of treatment in a patient with primary biliary cholangitis who has an inadequate alkaline phosphatase response but no symptoms of pruritus?
I usually will wait for a year with the first line agent, ursodiol, if it is well-tolerated and there are no symptoms, before declaring inadequate alkaline phosphatase response and moving on to a second line agent for primary biliary cholangitis.
How do you counsel patients about the potential benefits of laxatives when they are experiencing overflow diarrhea and are concerned about it getting worse with these medications?
I'll preface this by saying I rarely see this, and I will approach this answer as if this patient were in palliative care. But I think I would start with education on the mechanism of this type of diarrhea and the rationale for using laxatives to improve the situation. I would also discuss that, aft...