Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
How would you approach the evaluation of a patient with decompensated cirrhosis, suspect to be due to alcohol, who is not a liver transplant candidate with iron studies showing elevated saturation and ferritin over 1000?
The finding of elevated iron saturation (I suspect means above 55%) and high ferritin raises the diagnosis of true iron overload. Certainly, a Ferritin level above 1000, when the patient is not actively drinking, is consistent with cirrhosis. So, I would start phlebotomies if the Hgb >11-12 g/dL all...
How do you set practical referral and discharge criteria for a MASLD multidisciplinary clinic to capture high-risk phenotypes without being overwhelmed?
As former Director of the Penn State Health Fatty Liver Program, we structured our multidisciplinary MASLD clinic around risk stratification rather than diagnosis, with the explicit goal of capturing patients at genuine risk of progression while preserving clinic capacity. We relied on a two‑step tr...
What specific clinical and echocardiographic thresholds lead you to taper/de-escalate pulmonary hypertension therapy before liver transplant?
The goal in pulmonary hypertension therapy pre-transplant is to fulfill the MELD exception criteria in terms of mean pulmonary artery pressure, pulmonary vascular resistance, as well as right ventricular function by echo. Once those criteria are satisfied, maintain those PH therapy doses until the t...
In severe alcohol-associated hepatitis complicated by renal dysfunction or prolonged hospitalization, do you start medications for alcohol use disorder during the admission or defer until medical stabilization?
In this scenario, the priority is to understand what the patient's future will be. It may be a transplant, discharge home from a rehab facility, possibly need for dialysis, or even palliative care. Regardless, I would defer until medical stabilization.
How would you approach the management of asymptomatic ALT and GGT elevation in an older adult patient with depression with psychosis and without history of hepatitis who recently had dose of quetiapine increased and new initiation of SNRI?
The answer when you suspect drug-induced liver injury depends on the X elevation above normal of ALT and bilirubin. In addition, exclusion of other coexistent factors, i.e., alcohol use, metabolic risks, or other medications. From liver tox, quetiapine may elevate liver tests in 30% of patients. Bel...
In a PSC patient who has received liver transplant, what graft and/or patient factors predispose to a more rapid return of their disease and how do you manage these peri-operatively and post-transplant?
Unfortunately, there are not a lot of modifiable risk factors for recurrent PSC. If the patient has concomitant IBD, then good control of the disease helps to prevent risk. Other risk factors include young age, HJ anastomosis, female gender, and cold ischemia time. Not much we can do about these.
How do you determine the timing and frequency of therapeutic thoracentesis in patients with symptomatic hepatic hydrothorax?
It is determined by the patient's symptoms. The patient should also get a paracentesis if there is concomitant ascites, otherwise the pleural effusion will re-accumulate as soon as it is drained unless the ascites is removed.
How do you approach dosing beta blockers for variceal prophylaxis when the standard dose doesn’t achieve the target heart rate?"
The question is obsolete, actually, as the preferred beta-blocker for variceal prophylaxis is now carvedilol per AASLD guidelines as of 2024. Carvedilol is preferred given more optimal lowering of portal pressure as well as data supporting reduced risk of decompensation. Carvedilol is not titrated t...
How do you decide between proceeding with elective TIPS versus delaying for right-heart catheterization (and possible pulmonary hypertension therapy) when pre-TIPS TTE is borderline (e.g., mildly elevated TR velocity with preserved RV function) but portal decompression is clinically needed?
Can measure the pulmonary pressure at the time of TIPS with a proviso not to proceed if there is pulmonary hypertension.
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...