Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
How would you approach the treatment of a patient with solid food esophageal dysphagia and GERD without a detectable esophageal stricture on upper endoscopy?
I would obtain a barium esophagram followed by high-resolution esophageal manometry and 48-hour esophageal pH testing.
When patients meet criteria for more than one MASH-directed agent class, how do you sequence versus combine therapies in someone with high cardiovascular risk but borderline hepatic severity, and what surrogate-response threshold would make you comfortable escalating to dual therapy?
In a patient with high cardiovascular (CV) risk and only borderline hepatic severity, I generally prioritize a metabolically effective agent first, such as glucagon-like peptide-1 (GLP-1)-based therapy, given the dual CV and hepatic benefit, and reassess liver response before adding liver-directed t...
For opiate-related ileus in the postoperative setting, at what point do you consider trialing methylnaltrexone?
I personally have never used this particular PAMORA for post-op ileus. Despite some promising phase 2 trials indicating potential benefit, several Phase 3 RCTs evaluating this drug specifically for post-operative ileus showed no benefit in preventing nausea/vomiting or speeding up time to discharge ...
Do you obtain liver biopsy to confirm the diagnosis of cirrhosis if cirrhotic liver morphology is noted on imaging?
This question touches upon two interesting trends: 1) There is an increasing trend in Radiology to report "cirrhotic liver morphology" in the "Impressions" section. When you then review the Body of the report, often these cases are noted to only have a heterogeneous appearing liver with surface nodu...
What is your approach to isolated alkaline phosphatase without other laboratory abnormalities?
Assuming none of the other LFTs are abnormal, I would get a GGT. If GGT is elevated --> likely a hepatobiliary issue. Would consider age, medical history, and risk factors. If persistently elevated, could consider RUQ US + MRCP. Conditions like PSC or PBC are frequently discovered due to asymptomati...
What is your approach to symptom management in patients with infectious diarrhea?
When it comes to infectious diarrhea, I would consider a short course of loperamide for symptomatic relief, provided that my suspicion for C. diff colitis and/or dysentery is low. Antimotility agents in the setting of toxin-producing infectious diarrhea can increase the risk of toxic megacolon (in C...
Do 5HT4 agonists such as Metoclopramide actually lead to improvement in symptoms for patients with diabetes related gastroparesis?
Yes, sometimes when the gastroparesis is frequent or the symptoms are tough, I do use Reglan to help. By the time they wind up in the hospital, they are really willing to have me use anything on them that might help. I explain to every patient the side effects of Reglan, including tartive dyskinesia...
Do you avoid the use of GLP-1 R agonist therapy for treatment of obesity in patients with known gastroparesis?
Short answer: yes. Gastroparesis is a well-known side effect of GLP-1 RA therapy. It is dose-dependent, so some patients may tolerate smaller doses but not the highest ones. A recent head-to-head trial of semaglutide vs tirzepatide in obesity (Aronne et al., PMID 40353578) found similar rates of gas...
How do you decide when to initiate or restart diuretics in a cirrhotic patient with ascites if they are receiving a therapeutic paracentesis?
This question has two parts, one with a straightforward answer, the other with a much more nuanced answer, if I understand it correctly. Any patient receiving a therapeutic paracentesis should start/restart diuretics afterwards. Per the 2021 AASLD guidelines, one of the statements reads “LVP is the ...
If an IBD patient has only partial clinical response to a new biologic and or small molecule, do you extend the loading phase before transitioning to the maintenance dose/interval?
As long as the patient is continuing to improve, I try to continue “induction dosing” before transitioning to maintenance dosing. This is particularly true for upatacitinib. We register all our patients with the Pharma companies' patient assistance (bridge) programs to circumvent insurance companies...