Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
When noninvasive tests are discordant (e.g., low FIB-4 but elevated VCTE and ELF), what is your decision algorithm for initiating a GLP-1 receptor agonist for MASH, and what specific discordance threshold makes you revert to biopsy?
I rely more on vibration-controlled transient elastography (VCTE) than the Fibrosis-4 (FIB-4) index or the Enhanced Liver Fibrosis (ELF) score. I use FIB-4 as more of a screening tool to inform next steps rather than a definitive diagnostic assessment of fibrosis. If I am wary of my VCTE results, I ...
When do you consider giving IV albumin for severe hypoalbuminemia with third-spacing of fluid outside of standard indications (i.e., large-volume paracentesis, HRS, SBP, shock, etc.)?
On the wards, I do not treat the albumin number. Severe hypoalbuminemia with third spacing, by itself, is not an indication for IV albumin. The consistent signal from the literature is that albumin should not be used simply to raise serum levels or to “pull fluid back in” as an adjunct to diuretics....
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...
In Budd–Chiari presenting with acute liver failure (ascites/encephalopathy) but a technically amenable short-segment hepatic vein lesion, how do you decide between urgent decompression (TIPS/DIPS or recanalization) versus prioritizing expedited transplant listing?
I would work up this patient for transplant because the presence of encephalopathy is very concerning. If a proper transplant candidate, without contraindications, and not meeting criteria for status 1a, I would plan for the TIPS. The patient is likely already on rifaximin and lactulose.
In biopsy-confirmed F2 MASH with a lean BMI, what phenotype features (e.g., visceral adiposity, worsening glycemia/prediabetes, atherogenic dyslipidemia) most strongly push you toward a GLP-1 receptor agonist first versus a thyroid hormone receptor-beta agonist first versus upfront combination therapy?
I would favor a THR-beta agonist in a patient with atherogenic dyslipidemia and lean MASH as first-line therapy. However, if a patient has significantly impaired glycemic control or poorly controlled diabetes, this phenotype may prompt me to consider a GLP-1 receptor agonist first. I do not start bo...
After endoscopic control of variceal hemorrhage, what minimum safety bundle (timing, tube type/size, monitoring, and contraindications) do you require to place a small-bore nasoenteric tube within 24 hours for nutrition and hepatic encephalopathy therapy?
I usually wait at least 48 to 72 hours before placing a Dobhoff or Keofeed small-bore nasoenteric tube. This allows sufficient time for bands to create their local ulcers and then fall off, minimizing the risk of rehemorrhage.
What minimum cardiometabolic evaluation and treatment workflow do you recommend at the time of MASLD diagnosis in hepatology clinic?
Although there is no clear algorithm, the new 2026 ACC guidelines recommend checking ApoB and Lp(a) at least once in individuals who are high risk. I include those with MASLD on that list. Therefore, in addition to ensuring they have their usual metabolic labs checked (HbA1c, lipid panel, sometimes ...
With pan-genotypic treatment options available, when do you consider checking the genotype in patients with Hepatitis C?
As long as pangenotypic medications are available to you, there is no reason to check genotype anymore. However, in some situations, such as prisons or very restrictive insurance plans where only the older medications are available, it would be important to know the genotype.
In patients with MASLD, would you consider management with off-label metformin, pioglitazone (despite weight gain risk), GLP-1 RA, or simply intensify lifestyle and monitor?
In 2025, we should be assessing if patients are developing F2-F3 fibrosis especially with the use of non-invasive assessments (FIB-4 score, transient elastography, or MRI elastography), and then offering either Semaglutide or Resmetirom for these individuals w/ F2-F3, which are the only FDA approved...
In lean MASLD with visceral adiposity (and/or high-risk metabolic/genetic features) in an already physically active patient, when do you recommend additional weight loss versus focusing on diet quality and central adiposity reduction, and how do you monitor to avoid clinically meaningful loss of lean mass?
In lean MASLD, current practice guidance would prioritize reduction of visceral adiposity and improvement in metabolic health rather than pursuing arbitrary WL targets, particularly in patients who are already physically active and have a normal BMI. In this setting, I focus on diet quality (Mediter...