Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
How do you consider sending fungal studies in a patient with pneumonia?
This is a very good question. One that I’ve meant to look up for a while, so thank you for prompting me to do so. I agree with Dr. @Dr. First Last's answer (he is also my division chief!), but wanted to expand further. The articles I found most helpful are cited below.When to suspect a fungal pneumo...
How do you decide when to use acid-suppressive medications for GI prophylaxis when patients are on prolonged corticosteroid therapy?
We only use acid-suppressive medications for GI prophylaxis in patients treated with corticosteroids when they have additional risk factors for upper GI bleeding. Risk factors include concomitant NSAID or antiplatelet therapy, history of GI bleeding or peptic ulcer, age over 60 years, prednisone dos...
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...
Do you avoid terlipressin for patients with hepatorenal syndrome who have an elevated bilirubin level?
The CONFIRM trial excluded patients with Grade 3 acute on chronic liver failure (due to increased risk of pulmonary complications). There have also been concerns raised that using terlipressin on liver transplant candidates might improve their MELD score enough to jeopardize their spot on the waitin...
How do you counsel patients experiencing symptoms/complications of menopause who desire use of HRT if they have a history of known hepatic adenomas?
There is a strong recommendation to avoid estrogen-containing HRT in these patients. Depending on the severity of the symptoms and if they do not currently have adenomas, we may have a risk-benefit discussion regarding estrogen-based HRT and close imaging monitoring of adenoma development. Certainly...
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The question is obsolete, actually, as the preferred beta-blocker for variceal prophylaxis is now carvedilol per AASLD guidelines as of 2024.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...
In patients with MASLD and F2–F3 fibrosis, would you initiate Resmetirom even if they are not making active lifestyle changes?
Yes, many patients had an underlying metabolic disorder that is difficult/impossible to address with lifestyle interventions alone and will go on to progress in their liver disease if left alone. Now with the approval of Semaglutide in August 2025 by the FDA and the approval of Resmetirom, we have t...
Is the Enhanced Liver Fibrosis (ELF) test superior to the FIB-4 test in the diagnosis of MASLD?
In terms of diagnostic accuracy for advanced fibrosis in MASLD, ELF is superior to FIB-4; however, here are the caveats to consider: FIB-4 is a simple and readily available test that is best used to rule out advanced fibrosis (high negative predictive value), and ELF is best used to rule in advanced...
Can fatty liver disease present with elevations in alkaline phosphatase without other liver enzyme elevations (AST and ALT)?
It is very atypical but can occur. Patients usually have elevations in aminotransferases (usually ALT higher than AST) and there can be very mild concurrent elevations in alkaline phosphatase. An isolated alkaline phosphatase elevation should however prompt a more extensive serological work up as we...
How do you decide which GLP-1s to prescribe for obesity?
Unfortunately, it is the insurance companies who are making the decisions about which GLP-1 I can use, if at all. If insurance is not an issue, I will usually choose Zepbound over Wegovy due to its better efficacy (21% loss in studies vs 15%) and better tolerability. However, if patients are paying ...