Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
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...
What is your approach to the management of nodular regenerative hyperplasia of the liver in patients with SLE?
There are no large studies regarding the treatment of nodular regenerative hyperplasia (NRH) in systemic lupus erythematosus (SLE). It is rarely recognized, and the vast majority of reported cases are single-case reports, literature reviews, and a few very small case series. A Japanese autopsy serie...
When using vasoconstrictors for HRS-AKI, what MAP target do you use in practice (absolute MAP vs ΔMAP), and how do you adjust that target in patients with chronic hypertension, cirrhotic cardiomyopathy, or very low baseline MAP?
Aim for a mean arterial pressure (MAP) at least 10 mmHg higher than baseline when treating with norepinephrine. For terlipressin, it is not necessarily titrated to a MAP, but you will see an increase in MAP as a response.
Do you continue semiannual HCC surveillance after HBsAg loss in a non-cirrhotic patient with additional risk factors (e.g., first-degree family history of HCC and ongoing alcohol use), and what criteria drive that decision?
No
How do you decide on the timing and urgency of transplant evaluation when a patient recovering from alcohol-associated hepatitis has rapid biochemical improvement (MELD falls into the low teens) but persistent portal-hypertension features and frailty/sarcopenia?
This is a great question, but it needs to be individualized. First: What is the time interval since presentation till MELD drop? Second: What is the patient's age, and what other comorbidities may require attention before or for a transplant evaluation, in particular risks of coronary disease and he...
What is your approach to peri-operative risk stratification and optimization in patients with cirrhosis?
The VOCAL-Penn score is one piece of information that I use for risk stratification in patients with cirrhosis. I usually treat symptomatic decompensated cirrhosis first (hepatic encephalopathy, ascites, hepatic hydrothorax, hepatorenal syndrome, variceal bleeding), because the risk scores usually c...
How do you consider sending fungal studies in a patient with pneumonia?
This is a very good question. One that I’ve meant to look up for a while, so thank you for prompting me to do so. I agree with Dr. @Dr. First Last's answer (he is also my division chief!), but wanted to expand further. The articles I found most helpful are cited below.When to suspect a fungal pneumo...
How do you pragmatically approach a conversation about "liver detox"/"liver cleansers" when patients bring up this topic?
It's important to keep an open mind with the use of these products, as often people will want to take them despite what you might say. Having some experience with the use of these products (or at least their ingredients) will give the patient a comfort level with freely discussing their use with you...
Do you add elafibranor or seladelpar to UDCA within the first year of treatment in a patient with primary biliary cholangitis who has an inadequate alkaline phosphatase response but no symptoms of pruritus?
I usually will wait for a year with the first line agent, ursodiol, if it is well-tolerated and there are no symptoms, before declaring inadequate alkaline phosphatase response and moving on to a second line agent for primary biliary cholangitis.
What clinical features would raise your suspicion for IgG-4 related disease?
IgG4-related disease can affect multiple organs, leading to varied presentations. In the abdomen, patients can have symptoms secondary to pancreatitis and or biliary obstruction. In the liver, patients can present with a PSC-like picture (jaundice, cholangitis, ductal strictures/dilatation) that, un...