Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
Do you find there is any benefit to giving N-acetyl-cysteine in non-acetaminophen related acute liver failure?
Yes, we believe there is a modest benefit for non-APAP patients. The Acute Liver Failure Study Group did a placebo controlled double blind study of NAC use in non-APAP ALF. Here is the reference. This is not FDA-approved. They wanted a second study but this one took about 6 or 7 years to complete!Le...
When would you decide to pursue plasma exchange in a patient in acute liver failure due to sinusoidal obstruction syndrome?
I have not used plasma exchange in the treatment of SOS. The Plex may transiently decrease the hyperbilirubinemia associated with SOS, but to my knowledge, it does not address the underlying pathophysiology.
When do you pursue liver biopsy for assessment of DILI?
In the setting of an acute elevation of liver chemistry tests, DILI should always be considered in the differential diagnosis. If the serological workup for abnormal liver tests is unrevealing as well as abdominal imaging, expectant management should ensue with the discontinuation of any potential o...
How would you approach the management of drug-induced autoimmune hepatitis compared to non-drug-induced autoimmune hepatitis?
It is often difficult to differentiate between these two entities. A very rigorous history taking of potential culprits should be undertaken on each patient visit, including for the use of complementary medicines. The former can have some chronicity although, I think much less often than with the mo...
How do you approach fertility/family planning and counseling in patients with end-stage liver disease?
I refer to MFM for all my female patients to talk about family building, especially post transplant.
What management considerations do you keep in mind in the management of pregnant patients with autoimmune liver disease?
AIH should ideally be well-controlled for a year prior to pregnancy, as this duration is associated with a lower risk of gestational and postpartum flares and a lower risk of preterm birth. Steroids, azathioprine, and CNIs are safe for use in pregnancy (and lactation), so important to emphasize the ...
How does a patient who is PNPLA-3 positive (heterozygote or homozygote) impact how you formulate their therapeutic plan?
At this time, the PNPLA3 positive status (heterozygote or homozygote) does not impact my formulation of a therapeutic plan, as my decisions to treat (and how to treat) are based on underlying MASLD disease activity and severity. My treatment decisions are tailored to patients' underlying risk factor...
What factors into your choice to use craving-related medications (e.g., baclofen, naltrexone, acamprosate, etc.) in the management of alcohol use disorder?
When I discuss starting medications of alcohol use disorder (MAUD), we discuss reducing alcohol cravings, thereby reducing overall intake with the ultimate goal of abstinence with adjunctive psychotherapy if necessary. The options currently available in the market are naltrexone oral and intramuscul...
How do you approach a conversation with a patient with a markedly positive PETH (>200 ug/L) who is insistent that they do not consume any alcohol?
Falsely positive PETh results are very rare. A possible cause is transfusion of PRBC from a donor who was a drinker. False positives from lab error are possible, so repeating in a few days after patient denial is worth it. The endogenous production of small amounts of alcohol by gut microorganisms h...
How do you approach a patient who has incidentally found liver and renal cysts?
If has many cysts in both organs, then consider polycystic syndromes and should see a nephrologist and hepatologist. For liver cysts - determine if simple or complicated (irregular borders, thick septations) - if the latter then likely need sampling. regardless hepatic simple cysts not causing sympt...