Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
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 ...
In what scenario do you obtain ammonia levels in a patient with cirrhosis?
Very few people check ammonia levels now in patients with cirrhosis. It turns out that it’s not a really accurate measure, and it’s also difficult to draw and get to the laboratory. I think we need to use clinical judgment to diagnose encephalopathy and, of course, the opinion of close relatives.
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.
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...
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...
In a PSC patient who has received liver transplant, what graft and/or patient factors predispose to a more rapid return of their disease and how do you manage these peri-operatively and post-transplant?
Unfortunately, there are not a lot of modifiable risk factors for recurrent PSC. If the patient has concomitant IBD, then good control of the disease helps to prevent risk. Other risk factors include young age, HJ anastomosis, female gender, and cold ischemia time. Not much we can do about these.
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...