Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
In hospitalized patients treated for presumed overt hepatic encephalopathy who show no meaningful improvement after 48–72 hours of adequate therapy and precipitant management, what is your highest- yield next diagnostic step and what clinical features drive that prioritization?
At this point in the clinical care pathway, I would repeat an infectious workup (blood, urine, diagnostic paracentesis; occult infections are common in our cirrhotic patients) and perform a high-quality multiphasic cross-sectional imaging test to rule out hepatocellular carcinoma (HCC), portal vein ...
How do you decide when to use acid-suppressive medications for GI prophylaxis when patients are on prolonged corticosteroid therapy?
We only use acid-suppressive medications for GI prophylaxis in patients treated with corticosteroids when they have additional risk factors for upper GI bleeding. Risk factors include concomitant NSAID or antiplatelet therapy, history of GI bleeding or peptic ulcer, age over 60 years, prednisone dos...
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...
In compensated MASH cirrhosis with frailty/sarcopenia, how do you use GLP-1 receptor agonists safely—what lean-mass or functional monitoring strategy (and stopping/adjustment thresholds) do you use to prevent harmful weight-loss–associated muscle loss while pursuing cardiometabolic benefit?
In compensated MASH cirrhosis with frailty or sarcopenia, I use GLP-1 receptor agonists cautiously (and for non-MASH indications) and pair them with structured resistance exercise 2 days a week, adequate protein intake (1.2-1.5 g/kg/day), and baseline functional assessment rather than focusing on we...
What is your clinical pathway when a transplant candidate reports abstinence but has a positive phosphatidylethanol (PeTH), including how you confirm results and decide on addiction-medicine involvement and listing implications?
We address the discrepancy directly with the patient. If the liver disease is moderate, we decline the patient as a candidate and require enrollment in an AUD treatment plan along with monthly Peth testing in order to eventually list. Medicines to prevent cravings are offered at hospital discharge. ...
How do you decide which patients should pursue add-on bepirovirsen rather than continue indefinite nucleos(t)ide analogue monotherapy for noncirrhotic chronic HBV?
HBsAg quantitation to determine if they meet criteria Frank discussion that only 1 in 5 patients succeed and that the 6-month weekly injections do have a relatively high rate of significant adverse hematological and renal complications requiring close laboratory monitoring. So far, most patients h...
How do you determine when you would treat an identified spleno-renal shunt and how?
It is important to remember that the typical reason portal hypertension develops is to try and accommodate the increased resistance across the cirrhotic liver. A spleno-renal shunt is a congenital malformation that is often noted when a patient develops portal hypertension. Prior to TIPS, these were...
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 VOCAL-Penn scoring system to provide decompensation/mortality risk estimates and then provide guidance regarding volume resuscitation, anesthetic/sedation limits, and pain medication recommendations, avoiding NSAIDs and opiates where possible. I also advise care to monitor for de...
How do you differentiate portal-hypertensive ascites from multifactorial volume overload when imaging shows only small-volume ascites in cirrhosis with concomitant cardiac/renal dysfunction?
Primarily, try to get a sample of the fluid; even just 50-60 cc of fluid can be enough to run diagnostic studies to assess the etiology of portal hypertension. Other helpful tests would be a TTE and checking for proteinuria to try to pinpoint whether the heart or the kidneys are more problematic tha...
In patients with suspected CHE and major confounders (e.g., OSA, alcohol-related cognitive impairment, early dementia), what is your practical stopping rule for escalating HE-directed therapy before pivoting to a primary non-HE evaluation (sleep/medication/neurocognitive workup)?
I think it's reasonable to give the lactulose/rifaximin combination a reasonable try in this patient population without going overboard as to cause side effects. Achieving requisite bowel movements with lactulose should eliminate any HE component of AMS within 24-48 hours, and the guidelines suggest...