Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
What is your approach to the management of nodular regenerative hyperplasia of the liver in patients with SLE?
There are no large studies regarding the treatment of nodular regenerative hyperplasia (NRH) in systemic lupus erythematosus (SLE). It is rarely recognized, and the vast majority of reported cases are single-case reports, literature reviews, and a few very small case series. A Japanese autopsy serie...
Do you continue semiannual HCC surveillance after HBsAg loss in a non-cirrhotic patient with additional risk factors (e.g., first-degree family history of HCC and ongoing alcohol use), and what criteria drive that decision?
No
How do you decide on the timing and urgency of transplant evaluation when a patient recovering from alcohol-associated hepatitis has rapid biochemical improvement (MELD falls into the low teens) but persistent portal-hypertension features and frailty/sarcopenia?
This is a great question, but it needs to be individualized. First: What is the time interval since presentation till MELD drop? Second: What is the patient's age, and what other comorbidities may require attention before or for a transplant evaluation, in particular risks of coronary disease and he...
What is your approach to peri-operative risk stratification and optimization in patients with cirrhosis?
The VOCAL-Penn score is one piece of information that I use for risk stratification in patients with cirrhosis. I usually treat symptomatic decompensated cirrhosis first (hepatic encephalopathy, ascites, hepatic hydrothorax, hepatorenal syndrome, variceal bleeding), because the risk scores usually c...
How do you consider sending fungal studies in a patient with pneumonia?
This is a very good question. One that I’ve meant to look up for a while, so thank you for prompting me to do so. I agree with Dr. @Dr. First Last's answer (he is also my division chief!), but wanted to expand further. The articles I found most helpful are cited below.When to suspect a fungal pneumo...
How do you pragmatically approach a conversation about "liver detox"/"liver cleansers" when patients bring up this topic?
The first step would be to find out why the patient feels they need this and fully explore those concerns. Patients often have a sense of their own health status even without a specific diagnosis, and much can be discovered. Or they have been frightened by media consumption and require careful reass...
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 patients with MASLD, would you consider management with off-label metformin, pioglitazone (despite weight gain risk), GLP-1 RA, or simply intensify lifestyle and monitor?
In 2025, we should be assessing if patients are developing F2-F3 fibrosis especially with the use of non-invasive assessments (FIB-4 score, transient elastography, or MRI elastography), and then offering either Semaglutide or Resmetirom for these individuals w/ F2-F3, which are the only FDA approved...
Are there instances when you use diuretics for non-oliguric patients with volume overload in the setting of hepatorenal syndrome who have normal MAPs?
Absolutely. First, since most patients with HRS are oliguric and have low MAPs, I would look for alternative explanations for renal insufficiency. But, yes, if someone like this is volume overloaded, then I do use diuretics, often in conjunction with large volume paracentesis, to manage the volume o...
What is your approach to initiating naltrexone in patients with alcohol use disorder and co-occurring liver disease?
In patients with AUD and co-occurring liver disease, I think the hepatotoxicity concerns around naltrexone have historically been overstated relative to both the actual evidence and the hepatic risk of ongoing alcohol exposure itself. The original 1980s data that triggered the FDA hepatotoxicity war...