Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
What is your endoscopic approach to the management of refractory GAVE in persistently anemic patients?
Approaches that I use: Reduce PPI use if able. There is some data that PPIs may make GAVE/DAVE and PHG worse and on occasion, stopping PPI has improved the overall appearance. Some positive data regarding the use of beta blockers for GAVE, although not that great. Depending on the definition of ref...
How do you approach the use of the quantification of HBsAg titers in chronic hepatitis B infection who are eAg negative with viral suppression on treatment?
The use of hepatitis B quantitative surface antigen has been increasing in recent years. There b are several uses for it. A very low level indicates a high likelihood of S antigen clearance, so a patient, who might want to stop taking their nucs would be reassured if their level was less than 100. O...
How would you approach a referral for concern for hemochromatosis with ferritin elevation but otherwise normal iron studies?
Interesting questions, but lack of specifics about the degree of elevation and what constitutes normal iron studies makes it difficult to directly answer this question. However, there are well-recognized causes of elevated ferritin due to non-iron overloaded conditions, including increased apoferrit...
How would you approach the management of a patient with elevated iron saturation (60%) and ferritin (500s) with negative genetic testing for hemochromatosis?
I would approach this clinical scenario in the following manner: Always starting with good medical and family history first. Is there any history compatible with secondary hemochromatosis (i.e., history of blood or multiple iron transfusions)? Could the patient be tested for other non-282Y genetic ...
In what cases do you use baclofen for alcohol use disorder?
As Dr. @Dr. First Last mentioned, it's generally not a first-line choice (at least in the US). It is much more popular in Europe, but efficacy usually comes at notably higher doses. In one case series from 144 patients treated with baclofen in a French clinic, the mean maximum dose was 211 mg daily ...
With the growth of non-alcoholic beverages (e.g., NA beer, liquor, etc), how do you approach a patient's consumption of these products in the setting of alcohol related liver disease?
This is definitely a challenging conundrum to deal with. Historically, even the NA beverages would have 0.5% alcohol, so they weren't truly NA. With time, that has seemingly changed. Regardless, my approach is the same. I strongly advise against the idea that NA beverages are allowed. Mostly because...
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...
In patients with hepatitis B and co-infection with hepatitis D, given their increased risk of development of HCC, how do you approach screening for this?
Screening frequency is based on tumor-doubling size and not risk of HCC. Every 6 months, imaging is recommended + AFP. HDV patients should be screened if advanced fibrosis (F3-4) is present or VCTE > 9 kPA.
How do you counsel patients on the risks vs benefits of naltrexone for alcohol use disorder with persistently elevated liver enzymes?
Before answering this question, it is first important to point out that obtaining baseline liver function tests (LFTs) is not necessary before starting a patient on any formulation of naltrexone (oral or long-acting injectable XR). However, it is essential to consider if the patient has an underly...
When would you consider quantification of hepatitis B surface antigen as part of the treatment decision making process?
I rarely send it but others use it religiously. If patient wants to know how likely he/she will be able to stop antiviral treatment after a certain period of time, HBsAg titer can provide a guesstimate e.g fairly likely if HBsAg levels <100 IU/m but if > 1,000, extremely unlikely. But you can also j...