Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
Which patients would benefit from referral to a center with pancreatic function tests such as a secretin stimulation test?
The short answer is none. Secretin-stimulated pancreatic function tests are often used to diagnose "early" chronic pancreatitis and exocrine pancreatic insufficiency. The problem is that the test has poor accuracy for either condition. This is a test of pancreatic ductal cell function only, which is...
How do you decide between immediate liver transplant referral versus a time-limited “recompensation observation” period in patients with alcohol-related cirrhosis who present with a first decompensation and achieve early, verified abstinence?
It can be difficult to differentiate the two, so one never errs on the side of evaluating the patient for a transplant and then getting to know them and their support system a bit better. The more data and time you have to make such a decision, the better it is. Often, the natural history of the dis...
How do you think the advent of COCA (COlorectal Cancer detection with AI), which leads to incidental CRC detection, will affect your clinical practice?
Good question. COCA is interesting but very preliminary, and it's not clear how the tech (or concept) is different from CT colonography. There are several steps to go through, including validation in larger cohorts and finally a clinical validation study. Then there will be questions of resources, w...
What adjunctive therapies beyond an antisecretory agent (e.g., PPI, H2RA, etc.) do you find most helpful in managing the acute symptoms of PUD?
A meta-analysis of studies indicates that overall healing rates for duodenal ulcers with sucralfate range from 60% to 90% at 4-6 weeks of treatment. This data confirms sucralfate's effectiveness for its primary approved indication. The data for gastric ulcers is more nuanced and somewhat contradicto...
In patients with sarcoidosis and persistently elevated liver function tests, when do you consider initiating ursodeoxycholic acid (UDCA)?
In patients with systemic sarcoidosis with predominantly elevated alkaline phosphatase, I would be suspicious for liver involvement of their sarcoidosis. If treatment of the systemic sarcoidosis with immunosuppression (typically initiated by Pulmonology or Rheumatology) are ineffective for improving...
When giving albumin challenge, for acute kidney injury with suspected hepatorenal syndrome, do you administer a single dose daily or split the dose of albumin?
The main concern about albumin infusions is the potential risk for pulmonary edema (China et al., PMID 33657293). Therefore, I prefer to have albumin administered in divided doses of 25 grams at a time with a max daily dose of up to 100 grams, and I tend to stop IV albumin if the serum albumin level...
What is the preferred modality for evaluating for H pylori in patients with gastric bypass?
Evaluation of H pylori after gastric bypass would require stool examination for H pylori antigen or DNA.
Do you usually recommend a modified diet for Clostridioides difficile infection (CDI)?
Post-infection IBS is common after C. diff infection, and some of these patients have dietary intolerances. Other than avoiding foods that exacerbate these symptoms, I do not recommend any particular diet. I also do not recommend probiotics, in keeping with society guidelines.
Which GI cancer patients do you use oral contrast in staging CT scans?
We do not use oral contrast for most of our patients and only offer oral contrast CT scans for patients we are concerned about perforation.
What is your approach to iron deficiency anemia after a 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 ...