Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
Do you avoid peritoneal dialysis in cirrhotic patients with ascites?
There are two major concerns regarding the performance of PD in patients with ascites: the potential for fluid leakage at the site of the newly placed catheter and the perceived increased potential for peritonitis. In my experience, neither of these is a compelling reason to shy away from PD in a pa...
In current practice after DCD transplantation, what early clinical or laboratory signals push you to escalate beyond MRCP-first toward earlier ERCP or targeted hepatic arterial assessment for suspected ischemic cholangiopathy?
Persistently unexplained cholestasis.
Would you consider making a diagnosis of hepatorenal syndrome-associated acute kidney injury with a one-day diagnostic fluid challenge instead of a two-day challenge to expedite vasoconstrictor therapy if needed?
Depending on the circumstances, of course. If the patient is already significantly fluid overloaded, even one day of fluids may not be necessary. The main issue is renal vasoconstriction, as these patients are never truly total-body fluid depleted. The key question is whether the renal vasoconstrict...
How would you approach the management of asymptomatic ALT and GGT elevation in an older adult patient with depression with psychosis and without history of hepatitis who recently had dose of quetiapine increased and new initiation of SNRI?
The answer when you suspect drug-induced liver injury depends on the X elevation above normal of ALT and bilirubin. In addition, exclusion of other coexistent factors, i.e., alcohol use, metabolic risks, or other medications. From liver tox, quetiapine may elevate liver tests in 30% of patients. Bel...
How do you consider the clinical relevance of elevated serum B12 levels as a marker of underlying hepatic disease?
Elevated B12 levels have shown significant relevance and significance to many underlying conditions, particularly a high correlation with underlying liver disease. About 1 in 5 to 1 in 4 B12 levels >1000 pg/ml had a significant correlation. It is a prognosticator, in my opinion, and the literature s...
When pulmonary vasodilator therapy lowers PVR to transplant targets but causes systemic hypotension or worsening renal perfusion in decompensated cirrhosis, how do you adjust therapy (dose reduction, agent change, accepting higher PVR) while preserving both hemodynamic eligibility and overall transplant candidacy?
Fortunately, an uncommon problem, but when it does occur, careful dose reduction of the offending agent may help. Also, I would consider going from any offending oral medication to an inhaled prostacyclin to avoid/minimize systemic effects.
What is your approach to perioperative risk stratification and optimization in patients with cirrhosis?
The VOCAL-Penn score is one piece of information that I use for risk stratification in patients with cirrhosis. I usually treat symptomatic decompensated cirrhosis first (hepatic encephalopathy, ascites, hepatic hydrothorax, hepatorenal syndrome, variceal bleeding), because the risk scores usually c...
Would you consider adding a loop diuretic for patients with HRS type 1 who are on a stable dose of vasoconstrictors to enhance diuresis?
As a last resort, I would much rather do therapeutic paracentesis for fluid overload with albumin infusions.
How do you decide between proceeding with elective TIPS versus delaying for right-heart catheterization (and possible pulmonary hypertension therapy) when pre-TIPS TTE is borderline (e.g., mildly elevated TR velocity with preserved RV function) but portal decompression is clinically needed?
Can measure the pulmonary pressure at the time of TIPS with a proviso not to proceed if there is pulmonary hypertension.
In patients who meet Baveno VII NIT criteria for CSPH and are candidates for NSBB to prevent decompensation, when (if ever) do you still perform screening endoscopy before starting NSBB, and what specific findings would change your management?
I consider screening endoscopy along with NSBB in patients meeting criteria for CSPH who are also Childs B or C, based on favorable results from the CAVARLY TRIAL (Tevethia et al., PMID 39067870) that demonstrated reduced risk of bleeding in this patient subgroup with NSBB and band ligation of high-...