Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
How do you decide between anticoagulation or portal vein recanalization in a patient with portal vein thrombosis?
It depends on cirrhotic vs non-cirrhotic. For cirrhotic, best to reference the AASLD 2020 guidance here - Northup et al., PMID 33219529.For non-cirrhotic: important to determine the etiology as well as evaluate for a hypercoagulable state, including checking for JAK2 and CALR.If acute and non-occlus...
How do you decide whether to initiate semaglutide for MASH when alcohol intake is near MASLD/MetALD boundary ranges or fluctuates with intermittently positive PEth—specifically, do you require a documented period of reduction/abstinence before treatment, or do you start therapy with a modified monitoring/futility framework?
Typically, my approach is to ensure that alcohol is not contributing to their liver disease before initiating anti-fibrotic therapy. I usually counsel them and monitor their PETH testing serially. Sometimes, cutting out alcohol itself will help reduce their fibrosis level over time and may obviate t...
In suspected antibiotic-associated cholestatic DILI with jaundice and no obstructing lesion on MRCP, what specific clinical or laboratory trajectory triggers you to proceed to early liver biopsy to evaluate for evolving vanishing bile duct syndrome rather than continued close outpatient monitoring?
This is an important question because early awareness and a confirmed diagnosis will result in a better outcome. 1- Needs a clear history and exclusion of other potential etiologies. 2- Need to know whether the patient has underlying liver disease, i.e., metabolic dysfunction-associated steatotic li...
In patients entering AUD treatment who also have obesity/diabetes (a MetALD phenotype), how do you modify your thresholds for fibrosis assessment and for initiating AUD pharmacotherapy and metabolic therapy (e.g., GLP-1 receptor agonists) with the explicit goal of reducing future liver and cardiovascular events?
In patients with a MetALD phenotype entering AUD treatment, I do not lower fibrosis assessment thresholds but rather focus on the higher pre-test probability that they may have significant liver fibrosis; I apply standard guideline-based NIT cutoffs while ensuring timely and complete evaluation. I u...
How do you approach the workup for a patient with imaging showing features suggestive of cirrhosis?
It is important to clarify what features of the imaging are resulting in this diagnostic impression. Liver nodularity without other findings of cirrhosis is non-specific and does not make a diagnosis of cirrhosis. An incidental finding of a nodular liver with normal liver enzymes and normal platelet...
When considering liver transplantation after downstaging beyond Milan criteria, what minimum downstaging endpoints (AFP response, radiographic response/necrosis, and required duration of stability) do you use to justify proceeding to transplant to optimize long-term overall survival?
I see several scenarios that will help with the answer. Once successful downstaging is achieved and the patient has a living donor, they may proceed to transplant (if no checkpoint inhibitors for ideally 90 days or more than 30 days). If no living donor is available, and the patient has a low MELD s...
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...
In a patient with negative Hep B surface Ag, Hep B surface antibody+, and Hep B core antibody+ serologies, do you initiate antiviral prophylaxis (e.g. entecavir) prior to starting rituximab?
I would use entecavir for Hep B reactivation prophylaxis in this case - based on recommendations from AGA 2025 guidelines, which does classify b-cell depleting agents as higher risk for reactivation for both Hep B surface Ag-positive and Hep B surface Antigen neg/core positive patients. It should be...
What is your approach to a situation where DILI is suspected secondary to an important medication (e.g., anticoagulation, antibiotics, etc.), but the diagnosis is uncertain and the liver injury is relatively mild?
If the drug suspected to induce liver injury causes symptoms and ALT is >3 times the upper limit of normal (ULN), I would stop the drug and find an alternative. Even if no symptoms are present, I would stop if ALT is >5 times ULN. Any level increase of ALT below the above parameters would still requ...
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...