Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
How do you approach dosing beta blockers for variceal prophylaxis when the standard dose doesn’t achieve the target heart rate?"
The question is obsolete, actually, as the preferred beta-blocker for variceal prophylaxis is now carvedilol per AASLD guidelines as of 2024. Carvedilol is preferred given more optimal lowering of portal pressure as well as data supporting reduced risk of decompensation. Carvedilol is not titrated t...
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.
What is your approach to secondary prophylaxis and post-discharge planning after an acute esophageal variceal bleed in a patient with ongoing alcohol use disorder and major social barriers (uninsured, homeless)?
Obviously, these questions are moot in the setting of an acute variceal bleeding when a life-saving TIPS becomes necessary; we then deal with these issues afterwards. We frankly go as far as we can with medical/endoscopic therapy before considering TIPS as an option for repeated bleeding episodes, w...
Would you consider the use of prophylactic antibiotics in patients admitted with decompensated cirrhosis with AKI with Cr>1.2, with ascitic fluid protein <1.5 without SBP and/or hyponatremia/Bili >3?
Is this in generalized cases or cases of GIB? If GIB, yes, I would consider it. In just generalized cases, there is no real role for empiric antibiotics.
Do you use lactulose in acute liver failure, particularly in patients on continuous renal replacement therapy (CRRT) for ammonia or toxin clearance?
Generally lactulose should be avoided in the situation given limited benefit as well a tendency for ileus in ALF and potential for lactulose to cause bowel distention.
How do you differentiate portal-hypertensive ascites from multifactorial volume overload when imaging shows only small-volume ascites in cirrhosis with concomitant cardiac/renal dysfunction?
Primarily, try to get a sample of the fluid; even just 50-60 cc of fluid can be enough to run diagnostic studies to assess the etiology of portal hypertension. Other helpful tests would be a TTE and checking for proteinuria to try to pinpoint whether the heart or the kidneys are more problematic tha...
Do you have any concerns about lower extremity compression (e.g., compression stockings, intermittent pneumatic compression, etc.) worsening ascites in a patient with portal hypertension?
This is an interesting question, and I have to admit, not one I've thought about regularly. When I think of lower extremity compression and the contraindications, portal hypertension and ascites are not contraindications that immediately come to mind. I do understand the reasoning behind the questio...
How long do you typically treat patients with phentermine for weight loss and what clinical markers do you follow?
Phentermine has been available since 1959 and remains an affordable and effective medication option added to a full lifestyle-based weight management plan. In people who are generally healthy and without contraindications to the medication, I have had patients used in at least intermittently for sev...
For an HBsAg-positive healthcare worker performing exposure-prone procedures with low-level viremia and no fibrosis, what HBV DNA target (complete suppression vs a specific cutoff) do you use to justify antiviral therapy solely to reduce occupational transmission risk?
I thought I answered this already. From the legal perspective, the ADA protects physicians, as well as everyone else. However, before any surgery, the physician would need to add that risk to the consent form of contracting hepatitis B, which may not be too appealing to the patients, as they can’t b...
Which patients, if any, do you revert back to ultrasound screening for HCC after prior diagnosis/definitive treatment of HCC?
I don't revert back to U/S for these patients ever. It's not dissimilar from colorectal cancer screening - once you have colon cancer, it's not appropriate to use iFOBT or stool DNA screening anymore - it's lifelong colonoscopy screening. Likewise, for HCC, I continue to use AFP plus cross-sectional...