Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
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 ...
At what BMI or waist-circumference threshold do you opt to move from Fibroscan to other NILDA for fibrosis assessment?
The XL-validation study found a liver stiffness measurement (LSM) failure of 1% for the XL and 16% for the M probe, in patients with a BMI of 28 or above. In people with a BMI of 40 or above, the XL-probe failure was 5%, and the best predictor of failure was a skin-to-capsule distance (SCD) ≥25 mm (...
How do you decide between TCAs, SSRIs, SNRIs, Pregabalin & atypical antipsychotics for neuromodulation in IBS patients?
TCAs are the first-line neuromodulator for IBS pain, with SSRIs, SNRIs, pregabalin, and atypical antipsychotics filling specific niches based on predominant symptoms and IBS subtype. TCAs - Strongest evidence for abdominal pain (NNT ~4). Slow GI transit, making them ideal for IBS-D. Start amitriptyl...
Would you consider anti-IL-5 therapy (mepolizumab or benralizumab) to either prevent or treat the more severe manifestations of eosinophilic granulomatosis with polyangiitis, such as "infiltrative" (e.g., cardiomyopathy, pulmonary infiltrates, or gastroenteritis) or "vasculitic" (e.g., neuropathy, palpable purpura, or glomerulonephritis)?
Yes, I would consider early starting biologics for infiltrative EGPA.
Is there benefit to aggressively treating hemochromatosis in a patient who has already progressed to cirrhosis at the time of diagnosis?
The short answer is yes, there is a benefit to treating iron overload in a patient with hereditary hemochromatosis (HH) with cirrhosis. HH involves at least five mutations, most commonly in the HFE gene (common variants include C282Y and H63D), leading to hyperabsorption of iron and progressive accu...
Under what circumstances do you give chemotherapy for a nondiagnostic pancreas biopsy that is suspicious for adenocarcinoma?
Assuming it is a localized pancreatic abnormality and no "metastases," I would not give chemotherapy as such. If anything, I would consider surgical removal, which will also give the exact diagnosis. To start, chemotherapy is not curative (maybe if it were a lymphoma!). There may be some way of doin...
Is there a serum ammonium level for which you recommend initiation of dialysis in a patient with hepatic encephalopathy?
Because there is a very poor correlation between ammonia levels and hepatic encephalopathy, I do not make recommendations based on ammonia levels. My approach is to treat each case individually in consultation with our hepatology colleagues. If a patient has encephalopathy and is not responding to m...
In patients with a peptic esophageal stricture and LA Grade D esophagitis, do you dilate at index EGD or treat first with PPI therapy and defer dilation?
In our practice, generally speaking, we prefer to dilate on the repeat endoscopy, once the patient has been on twice daily PPI therapy and once the inflammation/esophagitis is hopefully under control. Overall, inflammation is the enemy of dilation.
For patients with celiac disease confirmed on endoscopy with characteristic endoscopic findings, do you routinely repeat EGD to document healing, or just follow up with serial serologies and repeat EGD only based on the absence of clinical response?
If a patient has been able to effectively avoid gluten and there is no diarrhea, labs are normal, and tissue transglutaminase (TTG) is normal, there is no need for a follow-up endoscopy. Follow-up endoscopy is indicated if there is suspicion that villous atrophy continues.
What antibiotic prophylaxis do you recommend for a cirrhotic patient with an upper GI bleed, if any, in light of the recent meta-analysis published in JAMA Internal Medicine?
This study highlights the lack of high-quality data supporting the recommendation for antibiotic prophylaxis in cirrhosis patients with upper GI bleeding. At my institution, we usually recommend a short course of 3 to 5 days, though some clinicians extend it to 7 days. If there is ongoing bleeding, ...