Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
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.
In biopsy-confirmed F2 MASH with a lean BMI, what phenotype features (e.g., visceral adiposity, worsening glycemia/prediabetes, atherogenic dyslipidemia) most strongly push you toward a GLP-1 receptor agonist first versus a thyroid hormone receptor-beta agonist first versus upfront combination therapy?
I would favor a THR-beta agonist in a patient with atherogenic dyslipidemia and lean MASH as first-line therapy. However, if a patient has significantly impaired glycemic control or poorly controlled diabetes, this phenotype may prompt me to consider a GLP-1 receptor agonist first. I do not start bo...
After endoscopic control of variceal hemorrhage, what minimum safety bundle (timing, tube type/size, monitoring, and contraindications) do you require to place a small-bore nasoenteric tube within 24 hours for nutrition and hepatic encephalopathy therapy?
I usually wait at least 48 to 72 hours before placing a Dobhoff or Keofeed small-bore nasoenteric tube. This allows sufficient time for bands to create their local ulcers and then fall off, minimizing the risk of rehemorrhage.
What minimum cardiometabolic evaluation and treatment workflow do you recommend at the time of MASLD diagnosis in hepatology clinic?
Although there is no clear algorithm, the new 2026 ACC guidelines recommend checking ApoB and Lp(a) at least once in individuals who are high risk. I include those with MASLD on that list. Therefore, in addition to ensuring they have their usual metabolic labs checked (HbA1c, lipid panel, sometimes ...
With pan-genotypic treatment options available, when do you consider checking the genotype in patients with Hepatitis C?
As long as pangenotypic medications are available to you, there is no reason to check genotype anymore. However, in some situations, such as prisons or very restrictive insurance plans where only the older medications are available, it would be important to know the genotype.
In lean MASLD with visceral adiposity (and/or high-risk metabolic/genetic features) in an already physically active patient, when do you recommend additional weight loss versus focusing on diet quality and central adiposity reduction, and how do you monitor to avoid clinically meaningful loss of lean mass?
In lean MASLD, current practice guidance would prioritize reduction of visceral adiposity and improvement in metabolic health rather than pursuing arbitrary WL targets, particularly in patients who are already physically active and have a normal BMI. In this setting, I focus on diet quality (Mediter...
Are there clinical contexts where you would not use spleen stiffness to drive endoscopy/NSBB decisions because you suspect the SSM signal is dominated by splenic congestion/hyperdynamic circulation rather than portal pressure, and how do you identify those contexts at the bedside?
Spleen stiffness measurements have recently become available when the technology was added to the vibration-controlled transient elastography equipment that measures liver stiffness. It is not invasive, and elevated spleen stiffness has been added to the Baveno criteria and other professional societ...
How do you triage PSC patients with multifocal, predominantly intrahepatic dominant strictures and recurrent cholangitis (without advanced cirrhosis) between ERCP (targeted minimal-contrast drainage), percutaneous drainage, and early transplant evaluation?
A lot to untangle from this one question: Recurrent cholangitis is an indication for liver transplantation even in the absence of cirrhosis. Once a patient has had two episodes of cholangitis within a year, that triggers a transplant evaluation in my practice. The challenge will be in the patient's...
In severe alcohol-associated liver disease with limited documented abstinence, what prospectively measurable psychosocial signals are sufficient for you to support expedited listing (treatment engagement, insight, caregiver reliability, objective toxicology strategy), and which findings reliably predict unacceptable relapse risk in your experience?
I will give an answer that is a bit more subjective than objective. There are certainly validated scoring systems (Stanford Integrated Psychosocial Assessment for Transplantation [SIPAT], Sustained Alcohol Use Post-Liver Transplant [SALT]) that can help assess psychosocial risk in all patients, espe...
In MASLD patients with high cardiometabolic risk who already meet a clear metabolic indication for a GLP-1 receptor agonist, how much fibrosis-stage certainty do you require before treating it as liver-directed MASH therapy (and documenting/monitoring it as such), versus starting for metabolic benefit and using NIT trends to decide on subsequent biopsy or add-on liver-specific therapy?
If you have the option to get it for type 2 diabetes, it is often more likely to be approved by insurance. There would be no fibrosis requirements and no follow-up on continuing to prove fibrosis staging requirements. Whoever submits for prior authorization can mention if the patient is stage 2 to 3...