Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
What are your diagnostic and treatment goals for a patient with cirrhotic cardiomyopathy?
Cirrhotic cardiomyopathy (CCM) affects almost a third of liver transplant candidates. In the absence of primary cardiac disease abnormalities, diagnosis is based on echocardiographic criteria that predict pre-transplant morbidity and mortality, may be reversible, but abnormalities may persist even a...
How do you approach a patient with discordant Fibroscan and serologic testing for fibrosis?
First, rule out confounding factors for discordance. Several factors can falsely elevate FibroScan readings, including active hepatic inflammation, recent alcohol use, hepatic congestion from heart failure, and recent food consumption. The FIB4 score is affected by age, platelet count, etc. When the...
How do you decide which GLP-1s to prescribe for obesity?
Unfortunately, it is the insurance companies who are making the decisions about which GLP-1 I can use, if at all. If insurance is not an issue, I will usually choose Zepbound over Wegovy due to its better efficacy (21% loss in studies vs 15%) and better tolerability. However, if patients are paying ...
How do you decide whether to use pharmacologic VTE prophylaxis in hospitalized patients with decompensated cirrhosis?
For all patients, I begin by using a standard risk prediction tool to determine if the patient is appropriate for pharmacologic VTE prophylaxis. At our institution, the Padua risk prediction tool is embedded in our electronic health record/admission set. Clinical guidelines- including those from the...
When ALT is persistently normal and HBV DNA is high but noninvasive markers suggest more advanced disease, how do you triage between biopsy, immediate antiviral therapy, or close observation—and which discordance patterns most strongly suggest “silent” progression in your experience?
ALT means absolutely nothing to me. High DNA is very contagious and much more likely to cause fibrosis and liver cancer, let alone the more replication, the more integration into the hepatocyte genome, which is the main cause of liver cancer. Liver biopsy has no role here either; fibrosis is not the...
How do you decide between urgent early liver transplant listing versus a time-limited “watchful waiting” strategy in critically ill severe alcohol-associated hepatitis with some signs of potential hepatic recovery?
Often, these decisions are very difficult to make and have to be individualized per patient. Of course, if a patient is responding biochemically to a course of corticosteroids, transplantation will be deferred (non-response or contraindication to steroids is usually a component of the evaluation of ...
Would you recommend phlebotomy for a patient with previously treated ALL and HBV reactivation both now in remission but with elevated liver enzymes and ferritin, and liver biopsy with widespread peri-canalicular moderate iron deposition and perisinusoidal fibrosis with focal periportal fibrosis?
The case presented is not unusual. Patients do not always recall the number of transfusions received. I favor secondary hemochromatosis. If her HGB is above 11-12 g/dL, she could tolerate phlebotomies. I would be gentle with the schedule of phlebotomies, maybe a couple in 1-2 months, and follow her ...
What is your approach to the management of post-TIPS hepatic encephalopathy?
In general, this will depend on if HE is provoked or unprovoked. Provoking factors such as infection, dehydration, medications (sedatives) or GI bleeding are reversible and often do not require aggressive HE treatment when the underlying trigger is removed. It may be reasonable to consider lactulose...
In AIH/PBC overlap with both hepatitis and cholestasis, how do you determine whether incomplete biochemical response at 6–12 months reflects undertreated AIH versus inadequately controlled cholestasis?
Overlap can be very challenging to treat. In this situation, it is reasonable to perform a repeat liver biopsy. If autoimmune hepatitis remains active, it would increase the IS.
What is your evaluation approach for a new patient referral for an incidentally found liver lesion?
Incidental liver lesions are common but need to be placed under a clinical scenario that may result in major clinical decisions regarding further diagnostic studies and management. Sex and age, size of the lesion, underlying liver disease known or just found, use of medications in particular estroge...