Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
In current practice after DCD transplantation, what early clinical or laboratory signals push you to escalate beyond MRCP-first toward earlier ERCP or targeted hepatic arterial assessment for suspected ischemic cholangiopathy?
Persistently unexplained cholestasis.
Would you consider making a diagnosis of hepatorenal syndrome-associated acute kidney injury with a one-day diagnostic fluid challenge instead of a two-day challenge to expedite vasoconstrictor therapy if needed?
Depending on the circumstances, of course. If the patient is already significantly fluid overloaded, even one day of fluids may not be necessary. The main issue is renal vasoconstriction, as these patients are never truly total-body fluid depleted. The key question is whether the renal vasoconstrict...
Would you consider adding a loop diuretic for patients with HRS type 1 who are on a stable dose of vasoconstrictors to enhance diuresis?
As a last resort, I would much rather do therapeutic paracentesis for fluid overload with albumin infusions.
In patients who meet Baveno VII NIT criteria for CSPH and are candidates for NSBB to prevent decompensation, when (if ever) do you still perform screening endoscopy before starting NSBB, and what specific findings would change your management?
I consider screening endoscopy along with NSBB in patients meeting criteria for CSPH who are also Childs B or C, based on favorable results from the CAVARLY TRIAL (Tevethia et al., PMID 39067870) that demonstrated reduced risk of bleeding in this patient subgroup with NSBB and band ligation of high-...
Do you avoid terlipressin for patients with hepatorenal syndrome who have an elevated bilirubin level?
The CONFIRM trial excluded patients with Grade 3 acute on chronic liver failure (due to increased risk of pulmonary complications). There have also been concerns raised that using terlipressin on liver transplant candidates might improve their MELD score enough to jeopardize their spot on the waitin...
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...
How do people approach non-HIV patients with hepatitis B, a negative Hepatitis B E antigen, normal LFTs and relatively low HBV DNA between 2000-20000?
Treatment of chronic Hep B is recommended to prevent maternal-fetal transmission, reactivation during chemotherapy, recurrence after liver transplantation, and in patients with decompensated cirrhosis. Treatment has been shown to reverse fibrosis and cirrhosis. Specifically referring to the above sc...
Is the Enhanced Liver Fibrosis (ELF) test superior to the FIB-4 test in the diagnosis of MASLD?
In terms of diagnostic accuracy for advanced fibrosis in MASLD, ELF is superior to FIB-4; however, here are the caveats to consider: FIB-4 is a simple and readily available test that is best used to rule out advanced fibrosis (high negative predictive value), and ELF is best used to rule in advanced...
In what scenario do you obtain ammonia levels in a patient with cirrhosis?
Very few people check ammonia levels now in patients with cirrhosis. It turns out that it’s not a really accurate measure, and it’s also difficult to draw and get to the laboratory. I think we need to use clinical judgment to diagnose encephalopathy and, of course, the opinion of close relatives.
For suspected drug-induced autoimmune-like hepatitis after the culprit drug is stopped and there is no advanced fibrosis, how do you decide immunosuppression duration and the relapse-free follow-up interval needed to confidently label it DI-ALH rather than classic AIH?
In cases of possible medication-induced AIH, I typically do not start a steroid-sparing agent and attempt to manage alone with corticosteroids. The duration of steroid use is individualized. If there are no steroid side effects or use concerns (i.e., in an older, diabetic patient), we pursue a slowe...