Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
How do you consider the clinical relevance of elevated serum B12 levels as a marker of underlying hepatic disease?
Elevated B12 levels have shown significant relevance and significance to many underlying conditions, particularly a high correlation with underlying liver disease. About 1 in 5 to 1 in 4 B12 levels >1000 pg/ml had a significant correlation. It is a prognosticator, in my opinion, and the literature s...
For liver transplant candidates with ‘stable’ obstructive proximal LAD disease on invasive angiography, what lesion- and patient-level features most strongly push you toward pre-transplant PCI despite bleeding risk, DAPT requirements, and potential listing delay?
If the patient is deemed a candidate for transplantation, even though the lesions is described as stable, a high proximal LAD lesion with stenosis of equal or greater than 70% would require PCI despite the risks. The definition "stable" or asymptomatic does not apply to assure no ischemic events dur...
For early HCC that is technically within transplant criteria, what patient- or tumor-related features (e.g., AFP behavior, frailty, rising MELD, multifocality) lead you to stop pursuing liver transplantation as the preferred strategy and instead recommend resection/ablation with surveillance?
My approach is the following: if there is a solitary tumor < 2-3 cm (BCLC A) in a favorable location, consider ablation (MWA) IF the patient has no other benefits to get to transplant (i.e., no clinically significant portal HTN). If the patient has no portal HTN and has BCLC A or good B (unilobar) a...
In patients with mixed drivers of liver disease (e.g., MASLD risk plus hazardous alcohol use), how do you operationally assign the primary etiology in your clinic, and does that choice change your counseling priorities or timing of transplant referral?
If alcohol use is present, regardless of cardiometabolic risk factors, alcohol use needs to be addressed first. Patients with hazardous alcohol use need to be screened for AUD (using something like the AUDIT-C) and treated for AUD if present (a study on AUD in MetALD found that ~5% had AUD). I expla...
How do you incorporate routine alcohol biomarkers (e.g., PEth) into hepatology care to support AUD recognition and ongoing monitoring without increasing shame-driven concealment, particularly in liver transplant candidates?
I try to incorporate the test into my general assessment of alcohol use. I ask the AUDIT-C questions. I tell the patient that I have included this test in their panel of tests. However, I often have a patient when I did not see them prior to getting a PEth. Here the key is to treat the result as a r...
At what BMI or waist-circumference threshold do you opt to move from Fibroscan to other NILDA for fibrosis assessment?
The XL-validation study found a liver stiffness measurement (LSM) failure of 1% for the XL and 16% for the M probe, in patients with a BMI of 28 or above. In people with a BMI of 40 or above, the XL-probe failure was 5%, and the best predictor of failure was a skin-to-capsule distance (SCD) ≥25 mm (...
In patients with sarcoidosis and persistently elevated liver function tests, when do you consider initiating ursodeoxycholic acid (UDCA)?
In patients with systemic sarcoidosis with predominantly elevated alkaline phosphatase, I would be suspicious for liver involvement of their sarcoidosis. If treatment of the systemic sarcoidosis with immunosuppression (typically initiated by Pulmonology or Rheumatology) are ineffective for improving...
Do you recommend restarting a GLP-1RA after bariatric surgery if the patient tolerated it before the surgery?
While there are no clear recommendations on whether/when to resume GLP-1 RA after bariatric surgery, current 2025 guideline statements (ASMBS, ADA, AACE, Obesity Society) and expert consensus documents suggest the following approach: Hold GLP-1RA in the acute perioperative period. For daily-dosed ...
Would you begin semaglutide in a morbidly obese patient with intermittent elevations in ALT (100s) and with significant hepatic steatosis but without significant fibrosis?
How was fibrosis identified? Based on the information provided, if the rest of the serologic workup was negative for liver disease, I would be comfortable starting semaglutide. Its cross-disease benefits are likely to be highly impactful in someone we are assuming has MASLD. Liver biopsy would be us...
Would you recommend radiation or chemoradiation in a patient with cholangiocarcinoma s/p surgery and adjuvant treatment with single hepatic metastasis 3 years later?
Challenging case and worthy of tumor board discussion. I would likely start systemic therapy, and if response, consider regional therapy with resection or SBRT, assuming the hepatic function is adequate (keep in mind, TARE can cause liver disease). I have one patient in a similar situation, now > 5 ...