Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
How do you counsel patients who experience diarrhea from mycophenolate mofetil (Cellcept)?
I have them stop the drug, and when their bowels are back to normal (usually just a couple of days), I resume with 1 tablet bid of mycophenolate mofetil (MMF, CellCept), then a few days later go up to 1 tab tid, a few days later 2 tabs bid... etc. I instruct them to go down to the most recent dose ...
In patients who meet Baveno VII CSPH rule-in by LSM but have potential confounders (e.g., heart failure/congestion, cholestasis, recent alcohol use), how do you decide whether LSM is sufficient to start and follow NSBB versus escalating to spleen stiffness, MRE, or HVPG?
I would like to answer by stating that the Baveno VIII consensus has been published in the Journal of Hepatology. First statement: LSM >10 kPa should be performed in fasting conditions; we use a minimum of 3 hours and complemented by another validated NIT of advanced fibrosis. Second statement: LSM ...
What is your approach to the management of post-TIPS hepatic encephalopathy?
In general, this will depend on if HE is provoked or unprovoked. Provoking factors such as infection, dehydration, medications (sedatives) or GI bleeding are reversible and often do not require aggressive HE treatment when the underlying trigger is removed. It may be reasonable to consider lactulose...
What vitamins and minerals do you check yearly for patients post gastric bypass surgery?
Following Roux-en-Y gastric bypass it is essential to monitor micronutrients, vitamins, and minerals because malabsorption and long-term complications may occur with improper care. Based on ASMBS 2016 Nutrition Guidelines, AACE/TOS/ASMBS 2019 updates, and Endocrine Society recommendations, here are ...
What would be your transfusion strategy for a patient with decompensated cirrhosis presenting with concomitant acute upper GI bleed and acute MI?
I would be guided by the patient's vital signs, response to crystalloids, and clinical findings for red cell transfusion decisions, more so than any hemoglobin/hematocrit determination. I would avoid plasma transfusion for INR/prothrombin time abnormalities unless the viscoelastic testing demonstrat...
Under what circumstances would you recommend early fecal microbiota transplantation over antibiotic treatment or bezlotoxumab in a patient with recurrent C. difficile infection?
Assuming donor stool is available, if the patient is not expected to need another course of antibiotics in the foreseeable future, I would recommend FMT.
How do you use gut microbiome or gut microbiota analysis in your clinical practice, if at all?
While I am presented with microbiome analyses on a regular basis by patients, I do not believe that these are useful, as we are still not there when it comes to defining the "normal" microbiome. This indeed may vary tremendously between individuals depending on age, gender, diet, geographic location...
Would you consider octreotide as an adjunctive therapy for patients experiencing an acute life-threatening hemorrhage, outside of standard indications such as variceal or AVM bleeding?
In very selective scenarios, when the patient is experiencing an acute life-threatening bleeding while variceal or AVM bleeding remains on the differential, yes, I would consider octreotide as an adjunctive therapy, but only as a bridge to definitive diagnosis and treatment and not as a substitute f...
Do you have any experience with using every 2-week GLP-1 therapy instead of weekly for cost reduction strategies in patients using it for weight maintenance?
My experience is limited and anecdotal, but I do have multiple patients who did biweekly GLP therapy to stretch out their prescriptions due to coverage issues that occurred due to some insurance policy change back in March. Most of the patients had success with biweekly dosing, as the half-life of t...
Which type of colonic polyps or mass-like lesions do you refer to an advanced endoscopist?
Generally speaking, endoscopists should remove all polyps that he or she can confidently remove as their skills and time schedule will allow. I would avoid sending polyps to an advanced endoscopist at a separate procedure simply because it would take longer or the lesion is in a "tough spot". On the...