Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
How do you differentiate portal-hypertensive ascites from multifactorial volume overload when imaging shows only small-volume ascites in cirrhosis with concomitant cardiac/renal dysfunction?
Primarily, try to get a sample of the fluid; even just 50-60 cc of fluid can be enough to run diagnostic studies to assess the etiology of portal hypertension. Other helpful tests would be a TTE and checking for proteinuria to try to pinpoint whether the heart or the kidneys are more problematic tha...
Do you have any concerns about lower extremity compression (e.g., compression stockings, intermittent pneumatic compression, etc.) worsening ascites in a patient with portal hypertension?
This is an interesting question, and I have to admit, not one I've thought about regularly. When I think of lower extremity compression and the contraindications, portal hypertension and ascites are not contraindications that immediately come to mind. I do understand the reasoning behind the questio...
How long do you typically treat patients with phentermine for weight loss and what clinical markers do you follow?
Phentermine has been available since 1959 and remains an affordable and effective medication option added to a full lifestyle-based weight management plan. In people who are generally healthy and without contraindications to the medication, I have had patients used in at least intermittently for sev...
For an HBsAg-positive healthcare worker performing exposure-prone procedures with low-level viremia and no fibrosis, what HBV DNA target (complete suppression vs a specific cutoff) do you use to justify antiviral therapy solely to reduce occupational transmission risk?
I thought I answered this already. From the legal perspective, the ADA protects physicians, as well as everyone else. However, before any surgery, the physician would need to add that risk to the consent form of contracting hepatitis B, which may not be too appealing to the patients, as they can’t b...
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...
What are your top takeaways from AASLD 2025?
A lot of interest and research in new steatotic liver disease classifications (MASLD, Met-ALD, and ALD) with interesting abstracts about assessment of alcohol use (PETH, AUDIT-C) and the number of metabolic comorbidities that occur in these classifications. Very robust clinical research workshop, as...
Which patient characteristics increase the diagnostic yield of A1AT level testing in newly diagnosed cirrhosis, and when should phenotyping be performed in addition to measuring levels?
We have issues with getting phenotypes paid for by Medicare and Medicaid, so I often send a level first. If the level is below 80 mg/dL, then I send the phenotype. Also, concern is raised in patients with FH of cirrhosis or emphysema, or the patient does not have other obvious risk factors for cirrh...
In DCD liver offers where NRP or hypothermic oxygenated perfusion is available, what donor/recipient factors are still absolute or near-absolute reasons to decline because of ischemic cholangiopathy risk?
Since the advent and subsequent rapid development of machine perfusion techniques, liver transplant programs are ever-broadening their consideration of previously thought to be "extended" donors. Risks of ischemic cholangiopathy may be linked to the expertise of the program in using machine perfusio...
How would you approach GLP-1/GIP agonist use for MASLD management in a patient who had a prior episode of pancreatitis?
If the etiology of pancreatitis has resolved (i.e., alcohol use and the patient has achieved abstinence or status post cholecystectomy for gallstone pancreatitis), then I may consider a repeat trial of GLP-1/GIP for MASH with fibrosis when there is a need to address the extrahepatic risk factors (ob...
For remote liver transplant recipients back under the care of a community gastroenterologist (or PCP), what should be the approach to new liver enzyme elevations?
Elevated liver enzymes in post-transplant patients who live far from their transplant center are a common challenging issue. Many factors will influence your recommendation to the local physician: height of enzyme elevation, cholestatic, hepatitic, or mixed profile, and associated symptoms (pain, fe...