Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
Do you consider holding PPIs in patients hospitalized with infections like pneumonia or C. diff colitis?
My practice is to try to get patients off PPIs if at all possible, and the hospital can be a good time to have that conversation with them. This is assuming no active indication for them (recent ulcer/upper GI bleed, H.pylori therapy, etc.) Use of PPIs has been associated with a higher incidence of ...
What are your top takeaways from AASLD 2025?
A lot of interest and research in new steatotic liver disease classifications (MASLD, Met-ALD, and ALD) with interesting abstracts about assessment of alcohol use (PETH, AUDIT-C) and the number of metabolic comorbidities that occur in these classifications. Very robust clinical research workshop, as...
Which patient characteristics increase the diagnostic yield of A1AT level testing in newly diagnosed cirrhosis, and when should phenotyping be performed in addition to measuring levels?
We have issues with getting phenotypes paid for by Medicare and Medicaid, so I often send a level first. If the level is below 80 mg/dL, then I send the phenotype. Also, concern is raised in patients with FH of cirrhosis or emphysema, or the patient does not have other obvious risk factors for cirrh...
What new or emerging therapies for autoimmune gastritis are available beyond iron and vitamin B12 replacement?
Though we recognize autoimmune gastritis (AIG) as an autoimmune disease that targets antigens expressed on parietal cells of the stomach, there are currently no effective treatments to reduce gastric inflammation and to prevent parietal cell loss. Back in the 1960s, small studies looked at the role ...
For remote liver transplant recipients back under the care of a community gastroenterologist (or PCP), what should be the approach to new liver enzyme elevations?
Elevated liver enzymes in post-transplant patients who live far from their transplant center are a common challenging issue. Many factors will influence your recommendation to the local physician: height of enzyme elevation, cholestatic, hepatitic, or mixed profile, and associated symptoms (pain, fe...
How do you decide which patients with upper GI bleeds should be monitored on telemetry?
Telemetry use has some standard indications in GI bleeding, specifically for patients with hemodynamic instability and significant cardiac comorbidities. Such situations include unresolved hypotension, >4 units transfused, known arrhythmia, and severe HFrEF. In these cases, I’m worried about someone...
How do you balance the need for diuretics from a volume perspective (Ex: ascites, edema) in decompensated cirrhotic patients and progressive renal dysfunction?
There is no discrete answer to this question. Much depends on the overall goal of care. For a transplant candidate, higher creatinine may be needed for transplant access and be tolerated, but risk need for post-transplant RRT. If goals are palliative, symptom control supersedes renal function.
In a patient with low (or normal) BMI but findings of steatosis on imaging, no cardiometabolic comorbidities, and very elevated CAP scores, what are your next diagnostic and therapeutic steps to identify the cause of their steatosis and subsequent management?
In addition to knowing the level of steatosis, liver stiffness values would be of most interest. Alcohol use should stop if there is any level of fibrosis. Lifestyle modifications (dietary/exercise) should be part of recommendations, but with a goal of around 5 % weight loss. If they have F2-3 fibro...
How do you manage/treat acute radiation-induced enteritis?
I have no problem with the excellent comments already made. However, I think it is important to add some comments. First - one needs to be sure that the patient truly has radiation enteritis. Many patients receiving abdominal radiation therapy have other issues that need to be explored first. For ex...
How would you approach the diagnosis and management of a patient with features of portal hypertension but normal HVPG and no cirrhosis on biopsy, in the setting of possible but atypical primary biliary cholangitis, and how would you evaluate for alternative causes of presinusoidal or non-cirrhotic portal hypertension?
PBC can sometimes present with non-cirrhotic portal hypertension, like nodular regenerative hyperplasia, but your patient's normal HVPG argues against this. Having said that, HVPG is not great for measuring presinusoidal portal hypertension. Given the "atypical" nature of your patient's PBC, I would...