Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
How would you approach the management of a patient with elevated iron saturation (60%) and ferritin (500s) with negative genetic testing for hemochromatosis?
I would approach this clinical scenario in the following manner: Always starting with good medical and family history first. Is there any history compatible with secondary hemochromatosis (i.e., history of blood or multiple iron transfusions)? Could the patient be tested for other non-282Y genetic ...
In what cases do you use baclofen for alcohol use disorder?
As Dr. @Dr. First Last mentioned, it's generally not a first-line choice (at least in the US). It is much more popular in Europe, but efficacy usually comes at notably higher doses. In one case series from 144 patients treated with baclofen in a French clinic, the mean maximum dose was 211 mg daily ...
In patients with hepatitis B and co-infection with hepatitis D, given their increased risk of development of HCC, how do you approach screening for this?
Screening frequency is based on tumor-doubling size and not risk of HCC. Every 6 months, imaging is recommended + AFP. HDV patients should be screened if advanced fibrosis (F3-4) is present or VCTE > 9 kPA.
How do you counsel patients on the risks vs benefits of naltrexone for alcohol use disorder with persistently elevated liver enzymes?
Before answering this question, it is first important to point out that obtaining baseline liver function tests (LFTs) is not necessary before starting a patient on any formulation of naltrexone (oral or long-acting injectable XR). However, it is essential to consider if the patient has an underly...
When would you consider quantification of hepatitis B surface antigen as part of the treatment decision making process?
I rarely send it but others use it religiously. If patient wants to know how likely he/she will be able to stop antiviral treatment after a certain period of time, HBsAg titer can provide a guesstimate e.g fairly likely if HBsAg levels <100 IU/m but if > 1,000, extremely unlikely. But you can also j...
What clinical scenario do you consider screening for hepatitis delta?
I test every new patient with at least a Delta antibody. If patients have elevated ALT but low level HBV DNA levels, I will get a HDV RNA as my first test.
Do you recommend starting naltrexone at discharge for alcohol use disorder in patients with decompensated cirrhosis secondary to alcohol use?
Although naltrexone is generally safe to use in patients with cirrhosis, I would be cautious to use it in patients with decompensated cirrhosis, since it is mainly metabolized in the liver. I usually use acamprosate in patients with decompensated cirrhosis, with high bilirubin, as long as renal func...
What variables do you weigh most heavily when choosing which copper chelation therapy you'll recommend for a patient?
I typically assess the state of the liver, do they have cirrhosis or not. Are they decompensated or not? Then I will assess do they have neurologic side effects or not.Using these questions helps me to decide whether they need chelation therapy or not. I will typically start with Trientine as I have...
What is your preferred approach to a patient with incidentally found low ceruloplasmin?
I repeat it, but also take a thorough history and physical with attention to a diagnosis of Wilson's disease. If repeat comes back less than 19 again, then 24 urine copper and liver US/fibroscan, and maybe optho exam.
How do you manage liver enzyme elevations in patients with PBC after starting elanifibranor?
It depends on what is elevated. If the ALP is increasing (or stable), did the patient stop UDCA or obetacholic acid when starting elafibranor? Is adherence to elafibranor an issue? Is the patient also on concomitant medications that have drug interactions? Statins can have DDI with PPARs. I would al...