Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
How do you determine when you would treat an identified spleno-renal shunt and how?
To add to Dr. @Dr. First Last's response, I mainly first look for these when there are cases of refractory or persistent episodes of hepatic encephalopathy. This would be the first symptom of a functionally significant SRS. If standard measures are not working for HE management, then I make sure we ...
How do you approach the optimization and risk stratification of a cirrhotic patient who is undergoing extra-hepatic abdominal (or other) surgery?
I primarily use the VOCAL-Penn scoring system to provide decompensation/mortality risk estimates and then provide guidance regarding volume resuscitation, anesthetic/sedation limits, and pain medication recommendations, avoiding NSAIDs and opiates where possible. I also advise care to monitor for de...
How do you differentiate portal-hypertensive ascites from multifactorial volume overload when imaging shows only small-volume ascites in cirrhosis with concomitant cardiac/renal dysfunction?
Primarily, try to get a sample of the fluid; even just 50-60 cc of fluid can be enough to run diagnostic studies to assess the etiology of portal hypertension. Other helpful tests would be a TTE and checking for proteinuria to try to pinpoint whether the heart or the kidneys are more problematic tha...
In patients with suspected CHE and major confounders (e.g., OSA, alcohol-related cognitive impairment, early dementia), what is your practical stopping rule for escalating HE-directed therapy before pivoting to a primary non-HE evaluation (sleep/medication/neurocognitive workup)?
I think it's reasonable to give the lactulose/rifaximin combination a reasonable try in this patient population without going overboard as to cause side effects. Achieving requisite bowel movements with lactulose should eliminate any HE component of AMS within 24-48 hours, and the guidelines suggest...
How do you counsel patients experiencing symptoms/complications of menopause who desire use of HRT if they have a history of known hepatic adenomas?
There is a strong recommendation to avoid estrogen-containing HRT in these patients. Depending on the severity of the symptoms and if they do not currently have adenomas, we may have a risk-benefit discussion regarding estrogen-based HRT and close imaging monitoring of adenoma development. Certainly...
Is there a serum ammonium level for which you recommend initiation of dialysis in a patient with hepatic encephalopathy?
Because there is a very poor correlation between ammonia levels and hepatic encephalopathy, I do not make recommendations based on ammonia levels. My approach is to treat each case individually in consultation with our hepatology colleagues. If a patient has encephalopathy and is not responding to m...
What is your approach to secondary prophylaxis and post-discharge planning after an acute esophageal variceal bleed in a patient with ongoing alcohol use disorder and major social barriers (uninsured, homeless)?
Obviously, these questions are moot in the setting of an acute variceal bleeding when a life-saving TIPS becomes necessary; we then deal with these issues afterwards. We frankly go as far as we can with medical/endoscopic therapy before considering TIPS as an option for repeated bleeding episodes, w...
When would you consider use of EUS guided liver biopsy over percutaneous and/or transjugular?
If data (labs, imaging) are not entirely compelling for a primary parenchymal or biliary issue, then EUS liver biopsy can be an efficient approach in addition to ERCP (saving the need for separate biopsy in the event that ERCP is non diagnostic).
After liver transplantation for Budd–Chiari in patients with persistent high-risk thrombophilia (e.g., MPN/APS/PNH) and prior splanchnic thrombosis extension, what is your standard long-term anticoagulation strategy and what objective findings prompt you to intensify or de-escalate it?
Patients with a cause of thrombophilia that is not correctable by liver transplantation should remain anticoagulated post-transplant and need to work closely with the hematologist for follow-up and choice of agents, depending on the disorder. These recommendations apply to JAK2 V617F, antiphospholip...
Is there benefit to aggressively treating hemochromatosis in a patient who has already progressed to cirrhosis at the time of diagnosis?
The short answer is yes, there is a benefit to treating iron overload in a patient with hereditary hemochromatosis (HH) with cirrhosis. HH involves at least five mutations, most commonly in the HFE gene (common variants include C282Y and H63D), leading to hyperabsorption of iron and progressive accu...