Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
For suspected drug-induced autoimmune-like hepatitis after the culprit drug is stopped and there is no advanced fibrosis, how do you decide immunosuppression duration and the relapse-free follow-up interval needed to confidently label it DI-ALH rather than classic AIH?
In cases of possible medication-induced AIH, I typically do not start a steroid-sparing agent and attempt to manage alone with corticosteroids. The duration of steroid use is individualized. If there are no steroid side effects or use concerns (i.e., in an older, diabetic patient), we pursue a slowe...
What is your approach in deciding when to start (or briefly defer) anticoagulation in newly diagnosed Budd–Chiari syndrome with large esophageal varices and very recent banding?
Generally, we start IV heparin immediately, even if recent banding performed. Bleeding from varices is caused by transmural pressure, not anticoagulation. So interventions to address portal pressure should be prioritized, including anticoagulation and TIPS as soon as feasible.
What would you your approach to evaluation and monitoring of a patient with elevated AMA and increased immunoglobulins with a low alkaline phosphatase?
The diagnosis of PBC requires 2 of the 3 following elements: Positive AMA, Elevated ALP, and Biopsy consistent with PBC. It is quite possible this person will develop an elevated ALP in time. I would follow liver enzymes yearly, but would not diagnose PBC until the ALP increases. I would start UDC...
How do you differentiate primary from secondary iron overload?
Medical history helps- transfusion history, chronic hemolytic anemias, ESRD on HD, and inflammatory conditions increase the risk of secondary iron. In my practice, I use MRI to help distinguish between primary and secondary iron overload. In primary iron overload, the iron will only be seen in the l...
What is your approach to the inclusion of simultaneous bariatric surgery at time of liver transplant, especially in MASLD/MASH cirrhotics?
Typically, a combined approach with liver transplantation and simultaneous weight loss surgery has been proposed for patients with a BMI above 30 and etiology of liver disease MASH. The workup is very similar to the usual workup of patients with ESLD requiring LT. The procedure of choice has been th...
What is your approach to discussions with patients about the MELD score, its use for prognostication of outcomes and decompensation?
l stress to patients the importance of MELD in predicting pre-transplant survival, and a lot of education is undertaken to apprise the patient and their family about the predictiveness of MELD. I also emphasize to patients that small increases or decreases in MELD may indeed not be indicative of a w...
If a patient has a low ceruloplasmin with normal 24 hours urine copper excretion, how would you go about an approach to evaluation of other disorders of copper metabolism as a cause of liver disease?
It depends on how low the ceruloplasmin is. If the level is undetectable, I would be worried that the 24hr urine result is spurious. In this case, I would repeat the studies, evaluate for KF rings, and consider genetic testing based on how concerned you are for Wilson disease (i.e., family history, ...
What is your approach to induction therapy and maintenance therapy for patients with autoimmune hepatitis?
Depending on the severity - if severe injury with jaundice, I admit for IV solumedrol. On an outpatient basis, will do prednisone 40mg daily - repeat labs in 1 week and if improved, start Imuran 2 mg/kg (up to 200 mg daily; TPMT testing has to be ok - otherwise will do MMF 500 mg daily and increase ...
For pediatric patients with iron overload (high ferritin and transferrin saturation), do you perform HFE screening first, or proceed to non-HFE gene sequencing upfront to evaluate for HJV mutation as well?
Because there is no recommended "screening" scenario for iron overload in pediatrics (especially with no family history), the question for me revolves around "why did the patient get tested in the first place?" If it were a routine screen for iron deficiency, which affects millions of children at an...
What is your endoscopic approach to the management of refractory GAVE in persistently anemic patients?
Approaches that I use: Reduce PPI use if able. There is some data that PPIs may make GAVE/DAVE and PHG worse and on occasion, stopping PPI has improved the overall appearance. Some positive data regarding the use of beta blockers for GAVE, although not that great. Depending on the definition of ref...