Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
In PSVD, what specific clinical/imaging or thrombophilia features would make you start pre- emptive anticoagulation before any documented PVT, and how do you monitor for net benefit (thrombosis prevention) versus harm (bleeding) in this population?
Porto-sinusoidal vascular disorder (PSVD) is a more recent umbrella term for a number of manifestations, e.g., nodular regenerative hyperplasia (NRH). There is no pre-emptive benefit to blood thinners. These patients can manifest the usual features of portal hypertension, including portal/splanchnic...
In patients with PBC and possible autoimmune hepatitis overlap on immunosuppression, how do you decide whether improvement in ALT/IgG after starting a PPAR agonist reflects adequate control of hepatitic activity versus nonspecific biochemical improvement, and how (if at all) does that influence immunosuppression adjustments?
It is important to establish how convincing the diagnosis of overlap is. I use several different sources of information: Histology: interface hepatitis with a rich lymphoplasmacytic infiltrate (predominant) plus bile duct injury, or bile duct injury predominant with little to no hepatitis. Serum ma...
Is there a role for use of GLP-1/GIP receptor agonists in the management of substance use disorders, whether or not they meet other inclusion criteria for their use?
Currently, we lack the RCTs to understand the full impact of GLP-1s on SUD outcomes. Most evidence is pre-clinical, observational, suggesting potential reductions in cravings and alcohol use. A recent RCT, lab study of semaglutide in non-treatment-seeking adults with AUD showed decreased alcohol con...
What are some practical tips for when a patient's consistently stated goals of care do not correlate with their actions?
First, it's important to remember that most of us have inconsistent beliefs. We both want to lose weight, and we want to eat chocolate cake; we want to get an A, and we want to go to the party. So when we see inconsistencies in others' beliefs, rather than being judgmental, we should get curious. Ou...
What is your practical approach to monitoring pruritus severity over time in PBC to guide treatment adjustments (e.g., daily vs interval numeric rating scales), especially when follow-up intervals are long and symptom scores can be variable?
I do not use rating scales outside the context of a research protocol. I ask the patient about pruritus, I observe the patient in clinic (e.g., are they scratching), I examine the patient for excoriations, and I follow serum fractionated bile acids. I also tell them to message me if symptoms develop...
How do you choose between a PPAR agonist, obeticholic acid, or a fibrate as second-line therapy in PBC with optimized ursodeoxycholic acid when the immediate priority is clinically significant pruritus but you also want to optimize long-term biochemical risk reduction?
Obeticholic acid (OCA/Ocaliva) was voluntarily withdrawn from the U.S. market in September 2025 following FDA safety concerns, making it unavailable as a practical option. It's also known to worsen pruritus. Currently, the preferred second-line therapies are two PPAR agonists—seladelpar (a PPARδ ago...
For cirrhotic patients that we take care of in the community, when should be the optimal timing of referral for liver transplantation aside from the MELD score?
This is a challenging issue for all doctors, both as the referring doctor and the transplant institution. We do not want to evaluate patients who are unlikely to be transplanted, but the MELD score is not an adequate reflection of all patients' disease severity. For our referring doctors, I never ha...
In lean MASLD with sarcopenia or visceral adiposity despite normal BMI, how do you prioritize resistance training/nutrition versus pharmacologic cardiometabolic prevention, and what metrics do you track to decide if the plan is working?
I don't think this is a dichotomous choice, as resistance training and nutrition are complementary to pharmacologic cardiometabolic prevention. From a pharmacologic perspective, I would be cautious with incretin-based therapies as these may worsen sarcopenia, especially in an already lean (i.e., nor...
In patients with MASLD/MASH, do you perform any cardiac testing to create a patient's risk profile, given that cardiac complications are the top cause of morbidity and mortality in this patient population (especially those with advanced fibrosis)?
Yes. I routinely perform cardiovascular risk assessment in patients with MASLD or MASH, but I recommend risk‑based cardiovascular evaluation rather than routine cardiac testing for all patients. Cardiovascular disease is the leading cause of morbidity and mortality in MASLD and MASH, particularly in...
Can fatty liver disease present with elevations in alkaline phosphatase without other liver enzyme elevations (AST and ALT)?
It is very atypical but can occur. Patients usually have elevations in aminotransferases (usually ALT higher than AST) and there can be very mild concurrent elevations in alkaline phosphatase. An isolated alkaline phosphatase elevation should however prompt a more extensive serological work up as we...