Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
How do you determine whether to limit volume removal during therapeutic paracentesis in a patient without acute or chronic kidney disease?
Large volume paracentesis (LVP) can lead to complications such as post paracentesis circulatory dysfunction. In patients who have ongoing acute renal failure, patients with borderline low blood pressure, or in patients who have a history of hyponatremia, LVP should be limited to 5L.
How do you approach a patient on anti-TNF with positive Quantiferon (previously negative) with negative chest x-ray and no symptoms?
Prior to routine screening for latent TB for patients receiving or about to receive TNF inhibitor therapy, there were reports of miliary TB developing after initiation of TNF inhibitors. Therefore, one cannot say that a negative chest x-ray and no symptoms means the patient is not at risk for develo...
Is there a role for use of JAK inhibitors instead of corticosteroids to induce clinical remission in those with severe ulcerative colitis?
Tofacitinib and upadacitinib are specifically approved for the treatment of moderately to severely active ulcerative colitis (UC), and both had steroid-sparing endpoints in their clinical trial programs. However, so do many of our newer therapies for UC. Both agents have demonstrated efficacy within...
How do you approach a patient with IgG4-related disease who has failed rituximab and mycophenolate and continues to rely on high-dose steroids?
Most cases of IgG4-RD respond to rituximab similar to the steroid treatment. When there is a lack of response to moderate dose steroid or rituximab, either the diagnosis is not IgG4-RD or the manifestation is not due to active IgG4-RD. In many cases, if treatment is delayed, fibrosis takes over the ...
How do you approach the treatment of Crohn's colitis in the setting of immunosuppression for liver transplant?
Good question, as additional immune suppression can increase the risk of infection. The anti-rejection drug mycophenolate can cause diarrhea, which could mimic a Crohn’s flare. I individualize Crohn’s therapy in a liver transplant patient. What type of Crohn’s do they have? What meds were they on pr...
How do you approach the treatment of UC with PSC and how do you position oral vancomycin against biologic therapies?
A number of case reports have suggested that oral vancomycin improved the course of PSC, but more rigorous clinical trials have failed to confirm the benefits. [Deneau et al., PMID 32946600. Assis & Bowlus., PMID 37084929]The treatment of neither UC nor PSC seems to affect the other condition. That ...
Would you consider sotalol to be a suitable non-selective beta blocker for primary prevention of variceal bleeding in a patient who requires sotalol for treatment of arrhythmia in the setting of Fontan-associated liver disease and clinically significant portal hypertension?
The answer to this question will need to be case-by-case, unfortunately.The short answer:The priority in this patient's case for using sotalol is likely the underlying heart disease and its associated arrhythmia, and this cardiac benefit would not be achieved by carvedilol and other NSBBs. Thus, it ...
How do you decide whether to place an NGT or PEG tube in patients with dysphagia precluding adequate PO nutritional intake?
There are several factors that go into the decision of PEG tube vs continued nutrition via a nasogastric feeding tube(NGT). Anticipated time to recovery of oral pharyngial function (especially in the most common underlying illness, which is stroke). NGT can stay in place for up to 2 months without...
Do you recommend routinely monitoring pancreatic markers such as amylase and lipase while receiving GLP1 R agonist or dual agonist therapies to determine their risk of pancreatitis?
Absolutely not. We know that changes in amylase and lipase levels on these drugs are very common. For example, if you look at the supplementary data across the SUSTAIN series of phase 3 trials with subcutaneous semaglutide, the average person had about a 15-30% rise in their amylase/lipase. Further,...
After confirming the patient is not on NSAIDs, how do you approach acute ileitis on biopsies in a patient without symptoms or with only mild loose stools?
Is diarrhea inflammatory? What is her level of calprotectin? A useful biomarker to follow. Aphthous ilieitis does not have risk features for progressive Crohn’s that, at least at this time, does not require an advanced agent. You can use symptomatic agents (loperamide, cholestyramine, etc.) to asses...