Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
How do you decide when to check a PEth level in patients hospitalized with alcohol-associated disease?
In my practice as a hospitalist and addiction medicine specialist, I use PEth (phosphatidylethanol) as an adjunctive tool to assess alcohol exposure over the preceding 2 to 4 weeks. I most commonly order it when the alcohol use history is unclear, when a patient's clinical presentation is highly sug...
What is your approach to the use of GLP-1 agonists in older adults with diabetes with or at risk of sarcopenia?
This is an important question to keep an eye on, given the broadening use and effectiveness of GLP-1 agonists for various conditions, especially diabetes, and for weight loss. Unfortunately, as is so often the case, major clinical trials in this area do not reflect the heterogeneity of older adults ...
What toxicity threshold would make you stop bepirovirsen while pursuing functional cure in a noncirrhotic patient with chronic HBV on suppressive nucleos(t)ide analogue therapy?
From the paper: "On the basis of a phase 2a randomized controlled trial assessing safety, tolerability, and antiviral activity of bepirovirsen, in which ALT elevations associated with HBsAg reductions were reported for NA-naïve patients, ALT increases were considered AEs of special interest. Class e...
What is your threshold for offering nucleos(t)ide analogue cessation in an HBeAg-negative, non- cirrhotic patient with low EOT qHBsAg (e.g., ~80 IU/mL), and which clinical factors would make you advise against stopping even with reliable follow-up?
I am not a big advocate of stopping nucs under most circumstances except for sAg loss. However, if the patient is really insistent and the sAg level is that low it might be OK, although many experts think <10 would be better. You have to inform the patient of a risk of a flare when stopping, to be s...
If you do not have easy access to shear wave elastography (aka Fibroscan), what do you recommend for non-invasive tests to determine if a MASLD patient has clinically significant portal hypertension and risk-stratify them?
Great question. I do magnetic resonance elastography (MRE), and if not possible, shear wave elastography (SWE). If I have access to only blood-based non-invasive liver disease assessment (NILDA), will then order enhanced liver fibrosis (ELF). However, for clinically significant portal hypertension (...
How would you manage a patient who presents with hair loss that began after they started a GLP-1 inhibitor?
If it fits with telogen effluvium, I recommend monitoring. Many patients will improve after this initial shedding and will not have long-term shedding or long-term thinning. If there is any underlying androgenetic alopecia or pattern hair loss, then starting treatment as you normally would is also r...
In routine cirrhosis practice, what are the main practical barriers to embedding evidence-based alcohol use disorder treatment within hepatology care?
The biggest barrier to providing care can be seen when we define the scope of practice and the training of hepatologists.Just like how some of us prescribe GLP1a to F2-F3 patients with MASH or provide lifestyle counseling to people with MASLD, but ultimately we do not provide as comprehensive care a...
What role, if any, does systemic therapy have in the treatment of HCC amenable to definitive locoregional therapy?
Systemic therapy currently has no established role in patients with hepatocellular carcinoma (HCC) undergoing potentially curative locoregional therapy, including surgical resection or ablation. Active surveillance remains the standard of care after curative-intent treatment, and no perioperative sy...
How do you evaluate and manage acute alcohol withdrawal when symptom-driven protocols are confounded/unreliable?
I developed a structured, objective approach centered on PAWSS risk stratification and standardized mMINDS plus RASS monitoring rather than relying solely on symptom-driven tools like CIWA. At intake, patients with suspected alcohol use disorder undergo PAWSS assessment, baseline mMINDS scoring, RAS...
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...