Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
How do you decide between TCAs, SSRIs, SNRIs, Pregabalin & atypical antipsychotics for neuromodulation in IBS patients?
TCAs are the first-line neuromodulator for IBS pain, with SSRIs, SNRIs, pregabalin, and atypical antipsychotics filling specific niches based on predominant symptoms and IBS subtype. TCAs - Strongest evidence for abdominal pain (NNT ~4). Slow GI transit, making them ideal for IBS-D. Start amitriptyl...
Do you consider holding PPIs in patients hospitalized with infections like pneumonia or C. diff colitis?
My practice is to try to get patients off PPIs if at all possible, and the hospital can be a good time to have that conversation with them. This is assuming no active indication for them (recent ulcer/upper GI bleed, H.pylori therapy, etc.) Use of PPIs has been associated with a higher incidence of ...
Is there benefit to aggressively treating hemochromatosis in a patient who has already progressed to cirrhosis at the time of diagnosis?
The short answer is yes, there is a benefit to treating iron overload in a patient with hereditary hemochromatosis (HH) with cirrhosis. HH involves at least five mutations, most commonly in the HFE gene (common variants include C282Y and H63D), leading to hyperabsorption of iron and progressive accu...
Do you refer all of your patients for EGD prior to initiation of atezolizumab/bevacizumab for advanced HCC?
Per the trial, this was required within 6 months of starting the study. However, in practice, I don't know that this strict rule would be necessary. For example, what if an EGD was done 10 months ago without varices? I don't think I would feel strongly about this. Similarly, if we could get one shor...
Under what circumstances do you give chemotherapy for a nondiagnostic pancreas biopsy that is suspicious for adenocarcinoma?
Assuming it is a localized pancreatic abnormality and no "metastases," I would not give chemotherapy as such. If anything, I would consider surgical removal, which will also give the exact diagnosis. To start, chemotherapy is not curative (maybe if it were a lymphoma!). There may be some way of doin...
Is there a serum ammonium level for which you recommend initiation of dialysis in a patient with hepatic encephalopathy?
Because there is a very poor correlation between ammonia levels and hepatic encephalopathy, I do not make recommendations based on ammonia levels. My approach is to treat each case individually in consultation with our hepatology colleagues. If a patient has encephalopathy and is not responding to m...
What is your preferred approach in treating recurrent bleeding from GAVE?
If repeated APC has not helped, I ask our advanced endoscopists to perform RFA. If it is a nodular GAVE, then banding is another option.
In patients with a peptic esophageal stricture and LA Grade D esophagitis, do you dilate at index EGD or treat first with PPI therapy and defer dilation?
In our practice, generally speaking, we prefer to dilate on the repeat endoscopy, once the patient has been on twice daily PPI therapy and once the inflammation/esophagitis is hopefully under control. Overall, inflammation is the enemy of dilation.
For patients with celiac disease confirmed on endoscopy with characteristic endoscopic findings, do you routinely repeat EGD to document healing, or just follow up with serial serologies and repeat EGD only based on the absence of clinical response?
If a patient has been able to effectively avoid gluten and there is no diarrhea, labs are normal, and tissue transglutaminase (TTG) is normal, there is no need for a follow-up endoscopy. Follow-up endoscopy is indicated if there is suspicion that villous atrophy continues.
Would you use upfront atezo/bev in a patient with HCC and untreated hepatitis?
Yes. I would not have concerns. For HBV, I would start treatment before or simultaneously. Studies have varied by protocol about the HBV viral load being under 500 or 100 but it is not clear this matters. There have not been flairs reported. In regards to HCV, again, not an issue for me.