Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
In a patient with alcohol associated decompensated cirrhosis characterized by variceal hemorrhage that has now “re-compensated” in the setting of alcohol abstinence and is currently on carvedilol, at what surveillance intervals do you perform EGD?
Can apply the latest Baveno VIII consensus to this patient and utilize FibroScan to see if resolution of CSPH to guide whether repeat EGD +/- carvedilol is still indicated.7.19. In patients with recompensated cirrhosis, CSPH resolution/persistence may be non-invasively assessed via liver (LSM) and s...
Do you start statins despite elevated transaminases in MASLD with advanced fibrosis and high cardiovascular risk?
Yes, the potential risk of hepatotoxicity from statins is overstated. In a large majority, statins are well-tolerated. Meanwhile, the cardiovascular risk in people with MASLD is very real. Cardiovascular disease remains the number one most common cause of death among patients with MASLD, not cirrhos...
Under which circumstances is there a role for reduction in immunosuppression post-SOT in a patient with recurrent CMV viremia and/or disease?
While the decision regarding immunosuppression is always up to the primary transplant team, as the infectious disease consultant, I always inquire about the ability to reduce immunosuppression during episodes of CMV syndrome or disease even if it is a first episode. This becomes even more important ...
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...
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 AUD patients with diabetes who start GLP-1 receptor agonists or SGLT2 inhibitors, do you change the intensity or timing of liver fibrosis monitoring, and which on-treatment signals (labs vs elastography vs clinical events) would you rely on to adjust follow-up?
I do not alter my surveillance for progression or regression of fibrosis when AUD patients with diabetes start GLP-1 receptor agonists or SGLT2 inhibitors. I favor FibroScan liver stiffness measurement in patients who have not reached cirrhosis. The interval I favor is every 6-12 months. In patients...
What role, if any, does systemic therapy have in the treatment of HCC amenable to locoregional therapy?
Systemic therapy currently has no established role in patients with hepatocellular carcinoma (HCC) undergoing potentially curative locoregional therapy, including surgical resection or ablation. Active surveillance remains the standard of care after curative-intent treatment, and no perioperative sy...
In autoimmune hepatitis patients on azathioprine who develop NRH/OPV features, how do you determine whether azathioprine is the driver versus AIH-related vascular injury, and what is your usual immunosuppression adjustment when portal hypertension is emerging but AIH control is fragile?
The development of NRH is related to the thiopurine, in this case azathioprine, which should be stopped. I'm not sure how valuable or even if possible, to determine the mechanism of the vascular injury, but AZA needs to be discontinued. The reasonable alternative is to start mycophenolate and try to...
How do you choose between hepatic vein recanalization/angioplasty-first versus early TIPS in chronic Budd–Chiari syndrome with refractory ascites and long-segment hepatic vein occlusion but relatively preserved synthetic function?
If the patient has relative preserved synthetic function, then a DIPS could be an option.
For a solitary ≤3 cm HCC with aggressive biology (e.g., rising AFP or rapid growth), what biology thresholds (AFP level or doubling time) would make you favor ablative-intent Y90 over other liver- directed options despite small tumor size?
For best outcomes, I recommend either MWA or TARE for this solitary (< 3 cm) lesion based on location and ability to get complete necrosis. In our tumor board, we ask IR which technique will give them the best outcome and often times it depends on location and both may work. I would make sure you di...