Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
Is there a serum ammonium level for which you recommend initiation of dialysis in a patient with hepatic encephalopathy?
Because there is a very poor correlation between ammonia levels and hepatic encephalopathy, I do not make recommendations based on ammonia levels. My approach is to treat each case individually in consultation with our hepatology colleagues. If a patient has encephalopathy and is not responding to m...
What is your approach to secondary prophylaxis and post-discharge planning after an acute esophageal variceal bleed in a patient with ongoing alcohol use disorder and major social barriers (uninsured, homeless)?
Obviously, these questions are moot in the setting of an acute variceal bleeding when a life-saving TIPS becomes necessary; we then deal with these issues afterwards. We frankly go as far as we can with medical/endoscopic therapy before considering TIPS as an option for repeated bleeding episodes, w...
When would you consider use of EUS guided liver biopsy over percutaneous and/or transjugular?
If data (labs, imaging) are not entirely compelling for a primary parenchymal or biliary issue, then EUS liver biopsy can be an efficient approach in addition to ERCP (saving the need for separate biopsy in the event that ERCP is non diagnostic).
After liver transplantation for Budd–Chiari in patients with persistent high-risk thrombophilia (e.g., MPN/APS/PNH) and prior splanchnic thrombosis extension, what is your standard long-term anticoagulation strategy and what objective findings prompt you to intensify or de-escalate it?
Patients with a cause of thrombophilia that is not correctable by liver transplantation should remain anticoagulated post-transplant and need to work closely with the hematologist for follow-up and choice of agents, depending on the disorder. These recommendations apply to JAK2 V617F, antiphospholip...
Is there benefit to aggressively treating hemochromatosis in a patient who has already progressed to cirrhosis at the time of diagnosis?
The short answer is yes, there is a benefit to treating iron overload in a patient with hereditary hemochromatosis (HH) with cirrhosis. HH involves at least five mutations, most commonly in the HFE gene (common variants include C282Y and H63D), leading to hyperabsorption of iron and progressive accu...
How do you foresee the integration of artificial intelligence in the management and evaluation of patients with liver lesions/tumors?
I believe it will have a major impact on the diagnosis, prognosis and response to therapy in the future for liver lesions.
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.