Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
Given the equivocal findings of NRG GI003, in which patients would you select for liver-directed proton therapy in the management of HCC?
Based on the results presented, there is not an indication to routinely recommend proton-based radiation for HCC. There are ongoing efforts to see if there is a subgroup that benefits from protons.
How do you incorporate routine alcohol biomarkers (e.g., PEth) into hepatology care to support AUD recognition and ongoing monitoring without increasing shame-driven concealment, particularly in liver transplant candidates?
I try to incorporate the test into my general assessment of alcohol use. I ask the AUDIT-C questions. I tell the patient that I have included this test in their panel of tests. However, I often have a patient when I did not see them prior to getting a PEth. Here the key is to treat the result as a r...
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 (...
In patients with sarcoidosis and persistently elevated liver function tests, when do you consider initiating ursodeoxycholic acid (UDCA)?
In patients with systemic sarcoidosis with predominantly elevated alkaline phosphatase, I would be suspicious for liver involvement of their sarcoidosis. If treatment of the systemic sarcoidosis with immunosuppression (typically initiated by Pulmonology or Rheumatology) are ineffective for improving...
Do you recommend restarting a GLP-1RA after bariatric surgery if the patient tolerated it before the surgery?
While there are no clear recommendations on whether/when to resume GLP-1 RA after bariatric surgery, current 2025 guideline statements (ASMBS, ADA, AACE, Obesity Society) and expert consensus documents suggest the following approach: Hold GLP-1RA in the acute perioperative period. For daily-dosed ...
Would you begin semaglutide in a morbidly obese patient with intermittent elevations in ALT (100s) and with significant hepatic steatosis but without significant fibrosis?
How was fibrosis identified? Based on the information provided, if the rest of the serologic workup was negative for liver disease, I would be comfortable starting semaglutide. Its cross-disease benefits are likely to be highly impactful in someone we are assuming has MASLD. Liver biopsy would be us...
Would you recommend radiation or chemoradiation in a patient with cholangiocarcinoma s/p surgery and adjuvant treatment with single hepatic metastasis 3 years later?
Challenging case and worthy of tumor board discussion. I would likely start systemic therapy, and if response, consider regional therapy with resection or SBRT, assuming the hepatic function is adequate (keep in mind, TARE can cause liver disease). I have one patient in a similar situation, now > 5 ...
How do you use objective frailty or sarcopenia measures to trigger transplant referral in patients with low MELD?
Frailty and sarcopenia in patients with end-stage liver disease increase pretransplant waitlist mortality and risks of extended stay and complications post-transplant. We all know that a low MELD may be influenced by several factors, and by including creatinine in its formula, sarcopenia may spuriou...
What factors make you recommend complete abstinence versus a harm-reduction target when counseling on alcohol use in patients with steatosis and ongoing moderate drinking?
I think a healthy adult can drink 1-2 drinks, once or twice a week at low risk. The issues of greater risk arise when even this level of consumption occurs in the setting of other factors (operating machinery), clinical states (pregnancy), or comorbidities (increased BMI, DM, concurrent chronic live...
How do you sequence TAVR versus liver transplant listing in candidates with severe aortic stenosis and decompensated cirrhosis when MELD is rising—what clinical features most strongly favor accelerating TAVR versus deferring valve intervention?
The response to this is not straightforward, as the decision depends on the severity of AS and the patient's severity of liver disease and transplant candidacy. The decision involves Cardiology and the liver team. In severe AS, TAVR may be indicated with no other viable option. Intervention risk, fr...