Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
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 ...
How are you treating MSI-H CRC in a liver transplant recipient on tacrolimus & sirolimus?
This is an important question; however, our experience in the metastatic colorectal cancer (mCRC) setting remains very limited. This patient underwent liver transplantation three years ago and has since developed dMMR/MSI-H metastatic colorectal cancer. The patient is currently receiving tacrolimus ...
How do you decide when to initiate or restart diuretics in a cirrhotic patient with ascites if they are receiving a therapeutic paracentesis?
This question has two parts, one with a straightforward answer, the other with a much more nuanced answer, if I understand it correctly. Any patient receiving a therapeutic paracentesis should start/restart diuretics afterwards. Per the 2021 AASLD guidelines, one of the statements reads “LVP is the ...
How do you decide whether to use pharmacologic VTE prophylaxis in hospitalized patients with decompensated cirrhosis?
For all patients, I begin by using a standard risk prediction tool to determine if the patient is appropriate for pharmacologic VTE prophylaxis. At our institution, the Padua risk prediction tool is embedded in our electronic health record/admission set. Clinical guidelines- including those from the...
When ALT is persistently normal and HBV DNA is high but noninvasive markers suggest more advanced disease, how do you triage between biopsy, immediate antiviral therapy, or close observation—and which discordance patterns most strongly suggest “silent” progression in your experience?
ALT means absolutely nothing to me. High DNA is very contagious and much more likely to cause fibrosis and liver cancer, let alone the more replication, the more integration into the hepatocyte genome, which is the main cause of liver cancer. Liver biopsy has no role here either; fibrosis is not the...
How do you decide between urgent early liver transplant listing versus a time-limited “watchful waiting” strategy in critically ill severe alcohol-associated hepatitis with some signs of potential hepatic recovery?
Often, these decisions are very difficult to make and have to be individualized per patient. Of course, if a patient is responding biochemically to a course of corticosteroids, transplantation will be deferred (non-response or contraindication to steroids is usually a component of the evaluation of ...
Would you recommend phlebotomy for a patient with previously treated ALL and HBV reactivation both now in remission but with elevated liver enzymes and ferritin, and liver biopsy with widespread peri-canalicular moderate iron deposition and perisinusoidal fibrosis with focal periportal fibrosis?
The case presented is not unusual. Patients do not always recall the number of transfusions received. I favor secondary hemochromatosis. If her HGB is above 11-12 g/dL, she could tolerate phlebotomies. I would be gentle with the schedule of phlebotomies, maybe a couple in 1-2 months, and follow her ...
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 is your approach to the management of post-TIPS hepatic encephalopathy?
In general, this will depend on if HE is provoked or unprovoked. Provoking factors such as infection, dehydration, medications (sedatives) or GI bleeding are reversible and often do not require aggressive HE treatment when the underlying trigger is removed. It may be reasonable to consider lactulose...
In AIH/PBC overlap with both hepatitis and cholestasis, how do you determine whether incomplete biochemical response at 6–12 months reflects undertreated AIH versus inadequately controlled cholestasis?
Overlap can be very challenging to treat. In this situation, it is reasonable to perform a repeat liver biopsy. If autoimmune hepatitis remains active, it would increase the IS.