Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
How do you approach HCC screening in patients with advanced fibrosis e.g., F3 on FibroScan?
We should first understand the underlying principles that defined the various cut-offs that resulted in this recommendation (eg, cost-effectiveness threshold for HCC screening, cut-offs for advanced fibrosis) and then go from there. Among patients with cirrhosis, the cost-effectiveness threshold wa...
Do you avoid peritoneal dialysis in cirrhotic patients with ascites?
There are two major concerns regarding the performance of PD in patients with ascites: the potential for fluid leakage at the site of the newly placed catheter and the perceived increased potential for peritonitis. In my experience, neither of these is a compelling reason to shy away from PD in a pa...
What techniques do you find most effective for visualization of rectal disease with intestinal ultrasound?
I am not sure that this is the correct use of "intestinal ultrasound". There is the transabdominal ultrasound technique that is taught to gastroenterologists who can use it at point of care for their UC and CD patients to assess the small bowel and the colon. If you want to specifically look at the ...
In light of recent measles outbreaks in the US, would you recommend an MMR booster for immunocompetent patients born before 1957?
I would not recommend a measles vaccine for a person born before 1957. This year has been chosen because people before born before 1957 have a very very high likelihood of having had measles because virtually all children got this highly contagious disease. On the other hand, there is no harm to get...
What are your go-to medical management options for high ileostomy output in patients with >100 cm of remaining small bowel?
First of all, you have to make sure that the patient's liquid intake is not composed of free water but an electrolyte solution at least 50% of the time. Metamucil at night Nana flakes in a milkshake at night Medication stepwise: Maximize loperamide Add diphenoxylate Add a PPI to reduce acid secre...
In patients with EGJOO on esophageal manometry, how do you approach subsequent testing for further evaluation?
In order to make a clinically relevant and conclusive diagnosis of EGJOO, patients must not only have manometric findings of EGJOO but also clinically important/related symptoms and at least one additional test which shows evidence of obstruction at the EGJ. This additional testing is with either a ...
Where do SIBO testing and/or empiric antibiotics fit into the management of patients with bloating, abdominal pain, diarrhea, constipation, or distention?
There are now consensus papers on breath testing from North America, Europe, Asia (and Australia), Brazil, and, most recently, Argentina. All state that SIBO testing is important in the management of these functional symptoms. We have shown that methane is a cause of constipation, and Hydrogen on br...
If an IBD patient has only partial clinical response to a new biologic and or small molecule, do you extend the loading phase before transitioning to the maintenance dose/interval? How do you navigate insurance coverage?
As long as the patient is continuing to improve, I try to continue “induction dosing” before transitioning to maintenance dosing. This is particularly true for upatacitinib. We register all our patients with the Pharma companies' patient assistance (bridge) programs to circumvent insurance companies...
How would you approach the consideration of continuing or ceasing colonoscopy for colon cancer screening in a relatively fit man in his 80s without a history of polyps on prior colonoscopies?
For someone in his 80s who has received good screening and never had polyps, continuing colonoscopy brings little benefit. The risks and difficulties from the procedure become greater with age, so, for most older adults, stopping routine screening is usually the better option for geriatric care. Whe...
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...