Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
What specific clinical and echocardiographic thresholds lead you to taper/de-escalate pulmonary hypertension therapy before liver transplant?
The goal in pulmonary hypertension therapy pre-transplant is to fulfill the MELD exception criteria in terms of mean pulmonary artery pressure, pulmonary vascular resistance, as well as right ventricular function by echo. Once those criteria are satisfied, maintain those PH therapy doses until the t...
In severe alcohol-associated hepatitis complicated by renal dysfunction or prolonged hospitalization, do you start medications for alcohol use disorder during the admission or defer until medical stabilization?
In this scenario, the priority is to understand what the patient's future will be. It may be a transplant, discharge home from a rehab facility, possibly need for dialysis, or even palliative care. Regardless, I would defer until medical stabilization.
How would you approach the management of asymptomatic ALT and GGT elevation in an older adult patient with depression with psychosis and without history of hepatitis who recently had dose of quetiapine increased and new initiation of SNRI?
The answer when you suspect drug-induced liver injury depends on the X elevation above normal of ALT and bilirubin. In addition, exclusion of other coexistent factors, i.e., alcohol use, metabolic risks, or other medications. From liver tox, quetiapine may elevate liver tests in 30% of patients. Bel...
In a PSC patient who has received liver transplant, what graft and/or patient factors predispose to a more rapid return of their disease and how do you manage these peri-operatively and post-transplant?
Unfortunately, there are not a lot of modifiable risk factors for recurrent PSC. If the patient has concomitant IBD, then good control of the disease helps to prevent risk. Other risk factors include young age, HJ anastomosis, female gender, and cold ischemia time. Not much we can do about these.
How do you determine the timing and frequency of therapeutic thoracentesis in patients with symptomatic hepatic hydrothorax?
It is determined by the patient's symptoms. The patient should also get a paracentesis if there is concomitant ascites, otherwise the pleural effusion will re-accumulate as soon as it is drained unless the ascites is removed.
How do you approach dosing beta blockers for variceal prophylaxis when the standard dose doesn’t achieve the target heart rate?"
The question is obsolete, actually, as the preferred beta-blocker for variceal prophylaxis is now carvedilol per AASLD guidelines as of 2024. Carvedilol is preferred given more optimal lowering of portal pressure as well as data supporting reduced risk of decompensation. Carvedilol is not titrated t...
How do you decide between proceeding with elective TIPS versus delaying for right-heart catheterization (and possible pulmonary hypertension therapy) when pre-TIPS TTE is borderline (e.g., mildly elevated TR velocity with preserved RV function) but portal decompression is clinically needed?
Can measure the pulmonary pressure at the time of TIPS with a proviso not to proceed if there is pulmonary hypertension.
Do you have any concerns about lower extremity compression (e.g., compression stockings, intermittent pneumatic compression, etc.) worsening ascites in a patient with portal hypertension?
This is an interesting question, and I have to admit, not one I've thought about regularly. When I think of lower extremity compression and the contraindications, portal hypertension and ascites are not contraindications that immediately come to mind. I do understand the reasoning behind the questio...
How long do you typically treat patients with phentermine for weight loss and what clinical markers do you follow?
Phentermine has been available since 1959 and remains an affordable and effective medication option added to a full lifestyle-based weight management plan. In people who are generally healthy and without contraindications to the medication, I have had patients used in at least intermittently for sev...
For an HBsAg-positive healthcare worker performing exposure-prone procedures with low-level viremia and no fibrosis, what HBV DNA target (complete suppression vs a specific cutoff) do you use to justify antiviral therapy solely to reduce occupational transmission risk?
I thought I answered this already. From the legal perspective, the ADA protects physicians, as well as everyone else. However, before any surgery, the physician would need to add that risk to the consent form of contracting hepatitis B, which may not be too appealing to the patients, as they can’t b...