Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
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...
How do you distinguish portopulmonary hypertension from group 3 or mixed-etiology PH in liver transplant candidates with COPD/ILD and elevated mPAP—what additional testing (PFTs/DLCO, CT, V/Q, ABG, repeat RHC maneuvers) or hemodynamic interpretation do you rely on before listing?
Certainly, PFTS and Chest CT help decide if another (possible group 3) major issue is evolving along in the setting of suspected or proven portopulmonary hypertension (POPH) by right heart cath. In my experience, the severity of the pulmonary hypertension (mPAP and PVR) is helpful. Rarely have I see...
What is your approach to liver transplantation candidacy in those with decompensated cirrhosis who have been treated for a solid-organ malignancy, such as oral SCC?
This is an important consideration as patients who receive a solid organ transplantation will be on significant immunosuppression, which can result in significant proliferation of an underlying malignancy and have worse treatment outcomes compared to non-immunosuppressed patients. Furthermore, patie...
In cirrhosis with suspected HRS-AKI and baseline CKD or chronically elevated creatinine, how do you define a clinically meaningful ‘improvement’ during an albumin trial (over 24–48 hours) to distinguish HRS-AKI from volume-responsive AKI?
If the acute rise in serum creatinine returns to the pre-AKI level, the patient has volume-responsive AKI.
In patients with MASLD and F2–F3 fibrosis, would you initiate Resmetirom even if they are not making active lifestyle changes?
Yes, many patients had an underlying metabolic disorder that is difficult/impossible to address with lifestyle interventions alone and will go on to progress in their liver disease if left alone. Now with the approval of Semaglutide in August 2025 by the FDA and the approval of Resmetirom, we have t...
In what scenario do you screen patients with hepatitis B for hepatitis D co-infection?
I routinely screen every patient once at an initial diagnosis of chronic hepatitis B.