Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
How do you approach the optimization and risk stratification of a cirrhotic patient who is undergoing extra-hepatic abdominal (or other) surgery?
I primarily use the VOCALPenn scoring system to provide risk estimates and then provide guidance regarding volume resuscitation, anesthetic/sedation limits, and pain medication recommendations. Ultimately, our job is not to "clear" someone but to provide as accurate a risk assessment to the surgical...
What clinical scenario do you consider screening for hepatitis delta?
I test every new patient with at least a Delta antibody. If patients have elevated ALT but low level HBV DNA levels, I will get a HDV RNA as my first test.
Do you recommend starting naltrexone at discharge for alcohol use disorder in patients with decompensated cirrhosis secondary to alcohol use?
Although naltrexone is generally safe to use in patients with cirrhosis, I would be cautious to use it in patients with decompensated cirrhosis, since it is mainly metabolized in the liver. I usually use acamprosate in patients with decompensated cirrhosis, with high bilirubin, as long as renal func...
What variables do you weigh most heavily when choosing which copper chelation therapy you'll recommend for a patient?
I typically assess the state of the liver, do they have cirrhosis or not. Are they decompensated or not? Then I will assess do they have neurologic side effects or not.Using these questions helps me to decide whether they need chelation therapy or not. I will typically start with Trientine as I have...
What is your preferred approach to a patient with incidentally found low ceruloplasmin?
I repeat it, but also take a thorough history and physical with attention to a diagnosis of Wilson's disease. If repeat comes back less than 19 again, then 24 urine copper and liver US/fibroscan, and maybe optho exam.
How do you manage liver enzyme elevations in patients with PBC after starting elanifibranor?
It depends on what is elevated. If the ALP is increasing (or stable), did the patient stop UDCA or obetacholic acid when starting elafibranor? Is adherence to elafibranor an issue? Is the patient also on concomitant medications that have drug interactions? Statins can have DDI with PPARs. I would al...
What patient factors guide your selection of maintenance therapies for a patient with autoimmune hepatitis?
I have no deep insight here. The goal is to try to get labs as normal as possible - also realizing that once achieved normal labs do not per se imply normal liver. Histological control lags biochemical control by years, hence the need for prolonged therapy and biopsies prior to withdrawal of therapi...
What is your approach to the management of anti-pruritic therapies in patients with cholestatic liver disease?
If the patient has PBC, the newer FDA PPAR drugs (elafibranor and seladelpar) for PBC have an anti-pruritic effect, though they are mainly approved to lower ALP and are thought to be disease-modifying. For PFIC and Allagille syndrome, IBAT inhibitors (odevixibat and maralixibat) are helpful and are ...
What kind of monitoring do you choose in patients at risk for reactivation of hepatitis B who are on immunosuppression?
For patients at high risk of reactivation, I initiate prophylaxis and, given high efficacy, I don’t routinely monitor (other than to schedule annual appointments to make sure patients are getting refills). Generally, these patients are getting routine labs done by their oncologist or rheumatologist....
All things being equal, what patient factors are you looking at in the selection of TAF or TDF in the management of hepatitis B?
If renal function is normal and bone density is not a concern, TDF is much less expensive and has excellent long-term safety.