Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
When noninvasive tests are discordant (e.g., low FIB-4 but elevated VCTE and ELF), what is your decision algorithm for initiating a GLP-1 receptor agonist for MASH, and what specific discordance threshold makes you revert to biopsy?
I rely more on vibration-controlled transient elastography (VCTE) than the Fibrosis-4 (FIB-4) index or the Enhanced Liver Fibrosis (ELF) score. I use FIB-4 as more of a screening tool to inform next steps rather than a definitive diagnostic assessment of fibrosis. If I am wary of my VCTE results, I ...
Do you add elafibranor or seladelpar to UDCA within the first year of treatment in a patient with primary biliary cholangitis who has an inadequate alkaline phosphatase response but no symptoms of pruritus?
I usually will wait for a year with the first line agent, ursodiol, if it is well-tolerated and there are no symptoms, before declaring inadequate alkaline phosphatase response and moving on to a second line agent for primary biliary cholangitis.
What clinical features would raise your suspicion for IgG-4 related disease?
IgG4-related disease can affect multiple organs, leading to varied presentations. In the abdomen, patients can have symptoms secondary to pancreatitis and or biliary obstruction. In the liver, patients can present with a PSC-like picture (jaundice, cholangitis, ductal strictures/dilatation) that, un...
In healthy living liver donors with a persistent postoperative bile leak, what leak- and patient- specific thresholds (e.g., drain output trend, biloma size, systemic inflammatory signs, duct anatomy) push you to early ERCP rather than continued percutaneous drainage and observation?
Typically, a bile leak would be noted because there are some objective findings which prompt an abdominal imaging study, i.e., fever, pain, rising liver chemistry tests, bilious output in Jackson-Pratt drains. A collection suspicious for a bile leak should be drained in order to avoid infection. Cut...
When do you consider giving IV albumin for severe hypoalbuminemia with third-spacing of fluid outside of standard indications (i.e., large-volume paracentesis, HRS, SBP, shock, etc.)?
On the wards, I do not treat the albumin number. Severe hypoalbuminemia with third spacing, by itself, is not an indication for IV albumin. The consistent signal from the literature is that albumin should not be used simply to raise serum levels or to “pull fluid back in” as an adjunct to diuretics....
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...
Pending final results, but in what scenario would you select bepirovirsen as opposed to established therapy for hepatitis B patients (ex: TAF or TDF)?
Bepe looks like the first drug that will be approved for the functional cure of hepatitis B. All patients with hepatitis B are potentially eligible for treatment. However, it is much more likely to be successful if the quantitative s Ag is below 3,000 or 1,000 IU. This is very good reason to start d...
Does your working phenotype for ‘new PAH after LT’ (occult POPH vs PAH unmasked after HPS resolution vs distinct post-LT vasculopathy) change what you actually do—specifically, who you screen more aggressively and when you initiate PAH therapy?
In pre-liver transplant patients with known hepatopulmonary syndrome (HPS), we do pay greater post-transplant attention to those considered to have "large intrapulmonary shunts," marked lung-brain uptake with technetium-99m macroaggregated albumin (⁹⁹ᵐTc-MAA) scanning (>30%) or poor response to 100%...
If a patient has persistent ascites requiring diuretics after TIPS, at what point do you consider re-evaluation of TIPS?
First, I always review the TIPS procedure report and make note of the initial HVPG that was measured prior to TIPS placement, the diameter that the TIPS stent was opened to, and the post-TIPS HVPG measured. If the initial HVPG is <10 mmHg, I would question the etiology of the liver disease, as this ...
What is your approach to a situation where DILI is suspected secondary to an important medication (e.g., anticoagulation, antibiotics, etc.), but the diagnosis is uncertain and the liver injury is relatively mild?
If the drug suspected to induce liver injury causes symptoms and ALT is >3 times the upper limit of normal (ULN), I would stop the drug and find an alternative. Even if no symptoms are present, I would stop if ALT is >5 times ULN. Any level increase of ALT below the above parameters would still requ...