Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
How do you evaluate and manage acute alcohol withdrawal when symptom-driven protocols are confounded/unreliable?
I developed a structured, objective approach centered on PAWSS risk stratification and standardized mMINDS plus RASS monitoring rather than relying solely on symptom-driven tools like CIWA. At intake, patients with suspected alcohol use disorder undergo PAWSS assessment, baseline mMINDS scoring, RAS...
What is your approach to initiating naltrexone in patients with alcohol use disorder and co-occurring liver disease?
In patients with AUD and co-occurring liver disease, I think the hepatotoxicity concerns around naltrexone have historically been overstated relative to both the actual evidence and the hepatic risk of ongoing alcohol exposure itself. The original 1980s data that triggered the FDA hepatotoxicity war...
Do you rely on HbA1c to monitor glycemic control in a patient with diabetes and compensated cirrhosis, given that advanced liver disease can systematically lower HbA1c independent of actual glucose control?
A1C is a great test, but it has many limitations. One major one is that it depends on red cell circulation time being normal for interpretation using common standards for average glucose values. Cirrhosis will potentially shorten red cell lifespan depending on associated complications and severity. ...
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 patients who develop severe precapillary PH within 6–12 weeks after LT, which potentially reversible post-transplant contributors do you prioritize ruling out before escalating PAH therapy because they are most actionable and most plausibly causal in your experience?
The development of pre-capillary pulmonary artery hypertension post-liver transplant in the timeframe mentioned can be extremely serious. Obviously, the most life-threatening concern to rule out is acute pulmonary embolism, which could cause fairly dramatic hemodynamic changes and right heart dysfun...
How do you manage anticoagulation/antiplatelet therapies with strong indications for uninterrupted therapy in the setting of urgent procedures?
If anticoagulation is absolutely contraindicated because of the bleeding risk of the procedure, then "bridging" will usually make the most sense, most of the time, with low molecular weight heparin such as enoxaparin. If dual antiplatelet agents are contraindicated, particularly in the first month a...
Do you obtain liver biopsy to confirm the diagnosis of cirrhosis if cirrhotic liver morphology is noted on imaging?
This question touches upon two interesting trends: 1) There is an increasing trend in Radiology to report "cirrhotic liver morphology" in the "Impressions" section. When you then review the Body of the report, often these cases are noted to only have a heterogeneous appearing liver with surface nodu...
In settings where alcohol use is commonly underreported, what is your preferred practical approach to reduce MASLD vs ALD misclassification in routine hepatology or primary care (structured AUD screening, targeted alcohol biomarkers such as PEth/EtG, or a combined attribution algorithm), and how do you operationalize it without undermining patient engagement?
My practical approach is a combined strategy: routine use of a structured alcohol assessment (AUDIT-C) alongside metabolic risk profiling, with targeted use of objective biomarkers such as PEth when the reported alcohol history is uncertain or discordant with the clinical picture. I frame these asse...
In patients with MASLD, would you consider management with off-label metformin, pioglitazone (despite weight gain risk), GLP-1 RA, or simply intensify lifestyle and monitor?
In 2025, we should be assessing if patients are developing F2-F3 fibrosis especially with the use of non-invasive assessments (FIB-4 score, transient elastography, or MRI elastography), and then offering either Semaglutide or Resmetirom for these individuals w/ F2-F3, which are the only FDA approved...
How would you manage a patient who presents with hair loss that began after they started a GLP-1 inhibitor?
If it fits with telogen effluvium, I recommend monitoring. Many patients will improve after this initial shedding and will not have long-term shedding or long-term thinning. If there is any underlying androgenetic alopecia or pattern hair loss, then starting treatment as you normally would is also r...