Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
In healthy living liver donors with a persistent postoperative bile leak, what leak- and patient- specific thresholds (e.g., drain output trend, biloma size, systemic inflammatory signs, duct anatomy) push you to early ERCP rather than continued percutaneous drainage and observation?
Typically, a bile leak would be noted because there are some objective findings which prompt an abdominal imaging study, i.e., fever, pain, rising liver chemistry tests, bilious output in Jackson-Pratt drains. A collection suspicious for a bile leak should be drained in order to avoid infection. Cut...
Pending final results, but in what scenario would you select bepirovirsen as opposed to established therapy for hepatitis B patients (ex: TAF or TDF)?
Bepe looks like the first drug that will be approved for the functional cure of hepatitis B. All patients with hepatitis B are potentially eligible for treatment. However, it is much more likely to be successful if the quantitative s Ag is below 3,000 or 1,000 IU. This is very good reason to start d...
Does your working phenotype for ‘new PAH after LT’ (occult POPH vs PAH unmasked after HPS resolution vs distinct post-LT vasculopathy) change what you actually do—specifically, who you screen more aggressively and when you initiate PAH therapy?
In pre-liver transplant patients with known hepatopulmonary syndrome (HPS), we do pay greater post-transplant attention to those considered to have "large intrapulmonary shunts," marked lung-brain uptake with technetium-99m macroaggregated albumin (⁹⁹ᵐTc-MAA) scanning (>30%) or poor response to 100%...
If a patient has persistent ascites requiring diuretics after TIPS, at what point do you consider re-evaluation of TIPS?
Some may still require some diuretics, particularly if lower extremity edema is an issue post-TIPS. Otherwise, if paracentesis is needed ~6 weeks after TIPS and the patient is free of HE, then consider IR dilating the TIPS further. When TIPS is for ascites, IR should really start with a small calibe...
In a living donor with persistent abdominal pain and new ascites on POD6 despite a 'normal' Doppler ultrasound, what discordant imaging findings or lab patterns prompt you to escalate to CT venography/angiography (or invasive venography) to rule out hepatic venous outflow obstruction?
Most liver transplant programs perform routine surveillance Dopplers on the first day or two post-operatively, looking for thrombosis, which is a risk post-live donor surgery, especially if there are concerns about functional graft volume. I would be concerned in this case for either an inflow or an...
At what BMI or waist-circumference threshold do you opt to move from Fibroscan to other NILDA for fibrosis assessment?
The XL-validation study found a liver stiffness measurement (LSM) failure of 1% for the XL and 16% for the M probe, in patients with a BMI of 28 or above. In people with a BMI of 40 or above, the XL-probe failure was 5%, and the best predictor of failure was a skin-to-capsule distance (SCD) ≥25 mm (...
How do you utilize liver assistive devices in the management algorithm of patients with acute liver failure?
In the setting of severe ALF, we use 2 extracorporeal liver support strategies, which include high dose CRRT for the management of hyperammonemia, and plasma exchange as an add on to CRRT if the patient develops shock. The goal of high-dose CRRT (with high dose at our center defined as at least 60 m...
When severe hepatopulmonary syndrome (PaO₂ <50 mmHg) coexists with borderline portopulmonary hemodynamics on therapy (e.g., mPAP high-30s with PVR ~3 WU), how do you sequence optimization and listing strategy, and what physiologic thresholds make you proceed to transplant versus defer for further pulmonary vascular optimization?
This clinical scenario is more common than previously thought. Other than oxygen supplementation for hepatopulmonary syndrome (HPS), there is no other specific therapy. Portopulmonary hypertension (PoPH) needs to be treated to reach the threshold of desired mean pulmonary arterial pressure (mPAP) of...
What antibiotic prophylaxis do you recommend for a cirrhotic patient with an upper GI bleed, if any, in light of the recent meta-analysis published in JAMA Internal Medicine?
This study highlights the lack of high-quality data supporting the recommendation for antibiotic prophylaxis in cirrhosis patients with upper GI bleeding. At my institution, we usually recommend a short course of 3 to 5 days, though some clinicians extend it to 7 days. If there is ongoing bleeding, ...
How do you adjust transplant-benefit–based decision-making for HCC patients with prior immune checkpoint inhibitor exposure, given the potential for increased peri-transplant rejection or graft loss?
Some programs aim not to proceed with transplantation (LT) for 1 month subsequent to the administration of immunotherapy in order to avoid rejection. However, this is not often feasible, and the reality is that the half-life of these medications can be closer to 50-60 days. My personal opinion is th...