Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
How do you choose between resmetirom and semaglutide in the treatment of MASH?
I write a disclaimer to start, because use of resmetirom ($5,000 per month) and semaglutide ($1,600 per month) at this time cannot be used across the board with any patient with hepatic steatosis. It's important to highlight how we characterize a patient's metabolic dysfunction associated steatotic ...
How would you approach a referral for concern for hemochromatosis with ferritin elevation but otherwise normal iron studies?
Interesting questions, but lack of specifics about the degree of elevation and what constitutes normal iron studies makes it difficult to directly answer this question. However, there are well-recognized causes of elevated ferritin due to non-iron overloaded conditions, including increased apoferrit...
How would you approach the management of a patient with elevated iron saturation (60%) and ferritin (500s) with negative genetic testing for hemochromatosis?
I would approach this clinical scenario in the following manner: Always starting with good medical and family history first. Is there any history compatible with secondary hemochromatosis (i.e., history of blood or multiple iron transfusions)? Could the patient be tested for other non-282Y genetic ...
In what cases do you use baclofen for alcohol use disorder?
As Dr. @Dr. First Last mentioned, it's generally not a first-line choice (at least in the US). It is much more popular in Europe, but efficacy usually comes at notably higher doses. In one case series from 144 patients treated with baclofen in a French clinic, the mean maximum dose was 211 mg daily ...
With the growth of non-alcoholic beverages (e.g., NA beer, liquor, etc), how do you approach a patient's consumption of these products in the setting of alcohol related liver disease?
This is definitely a challenging conundrum to deal with. Historically, even the NA beverages would have 0.5% alcohol, so they weren't truly NA. With time, that has seemingly changed. Regardless, my approach is the same. I strongly advise against the idea that NA beverages are allowed. Mostly because...
How do you approach the workup for a patient with imaging showing features suggestive of cirrhosis?
It is important to clarify what features of the imaging are resulting in this diagnostic impression. Liver nodularity without other findings of cirrhosis is non-specific and does not make a diagnosis of cirrhosis. An incidental finding of a nodular liver with normal liver enzymes and normal platelet...
What is your approach to a situation where DILI is suspected secondary to an important medication (e.g., anticoagulation, antibiotics, etc.), but the diagnosis is uncertain and the liver injury is relatively mild?
If the drug suspected to induce liver injury causes symptoms and ALT is >3 times the upper limit of normal (ULN), I would stop the drug and find an alternative. Even if no symptoms are present, I would stop if ALT is >5 times ULN. Any level increase of ALT below the above parameters would still requ...
In patients with hepatitis B and co-infection with hepatitis D, given their increased risk of development of HCC, how do you approach screening for this?
Screening frequency is based on tumor-doubling size and not risk of HCC. Every 6 months, imaging is recommended + AFP. HDV patients should be screened if advanced fibrosis (F3-4) is present or VCTE > 9 kPA.
How do you counsel patients on the risks vs benefits of naltrexone for alcohol use disorder with persistently elevated liver enzymes?
Before answering this question, it is first important to point out that obtaining baseline liver function tests (LFTs) is not necessary before starting a patient on any formulation of naltrexone (oral or long-acting injectable XR). However, it is essential to consider if the patient has an underly...
When would you consider quantification of hepatitis B surface antigen as part of the treatment decision making process?
I rarely send it but others use it religiously. If patient wants to know how likely he/she will be able to stop antiviral treatment after a certain period of time, HBsAg titer can provide a guesstimate e.g fairly likely if HBsAg levels <100 IU/m but if > 1,000, extremely unlikely. But you can also j...