Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
How do you rule out spontaneous bacterial peritonitis in a patient with minimal ascites that is not amenable to paracentesis?
You can’t, unfortunately. You either need to keep looking for a good pocket (move patient to each side, etc.) or use clinical judgement and decide whether or not to treat empirically.
At follow-up around 72 weeks, what degree of noninvasive-test nonresponse would prompt you to stop a GLP-1 receptor agonist prescribed specifically for MASH (even if weight and aminotransferases improve), and what objective criteria do you use in the absence of validated futility rules?
When using GLP-1 as liver-directed pharmacotherapy for the treatment of MASH, liver-related endpoints to assess therapeutic efficacy include >/= 30% relative reduction in MRI-PDFF, decrease in ALT >/= 20%, decrease in VCTE >/= 30%, or MRE-LSM >/=20%. Refer to AASLD Guidance for use of semaglutide fo...
Do you prescribe a low-dose tricyclic antidepressant as a gut-brain neuromodulator for a patient with IBS that has not responded to dietary modification and first-line pharmacotherapy?
Yes, I do. In fact, I consider a tricyclic like imipramine (highest GI effects) to be first-line pharmacotherapy.
In patients with PBC and possible autoimmune hepatitis overlap on immunosuppression, how do you decide whether improvement in ALT/IgG after starting a PPAR agonist reflects adequate control of hepatitic activity versus nonspecific biochemical improvement, and how (if at all) does that influence immunosuppression adjustments?
It is important to establish how convincing the diagnosis of overlap is. I use several different sources of information: Histology: interface hepatitis with a rich lymphoplasmacytic infiltrate (predominant) plus bile duct injury, or bile duct injury predominant with little to no hepatitis. Serum ma...
Would you consider a combination of anti-TNF therapy and azathioprine upfront in a young male with Crohn’s disease considering its risk of lymphoma in the era of several advanced therapies?
Definitely, TNF + IMM hasn’t been beaten in efficacy. If the patient is in clinical and endoscopic remission at 6-12 months with good IFX levels, then they can stop the IMM.
What is your approach to terminal ileal structure in the setting of a new diagnosis of Crohn’s disease on index colonoscopy?
If there have been episodes of symptomatic obstruction or if there is proximal dilation on imaging, I would forgo any medical therapy and move straight to resection.
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 approach the management of patients who require nutritional restoration in the setting of a presumed functional GI disorder recalcitrant to behavioral medicine and pharmacologic therapies?
It certainly is a very good question if indeed the patient has functional disease; then, for sure, they need more than just my help. They probably need the help of a nutritionist, but even more so, they need perhaps psychiatric medication and the treatment of a behavioral therapist or psychological ...
What is your approach to explaining the role of the microbiome to patients with inflammatory arthritis?
The gut microbiota play a central role in modulating the inflammatory response. This is especially relevant to inflammatory arthritis, where the pathogenesis is quite well understood, especially as it relates to arthritis associated with inflammatory bowel disease. We also know that the diet is the ...
Have you used oral vancomycin as prophylaxis for C difficile infection in patients admitted for allogeneic hematopoietic cell transplant?
Yes, but only in patients with a history of C difficile in the previous year and starting at the time of initiation of broad-spectrum antibiotics (e.g., for fever and neutropenia). We use 125 mg daily.We are aware this practice may be controversial. To my knowledge, there is only one randomized tria...