Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
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The question is obsolete, actually, as the preferred beta-blocker for variceal prophylaxis is now carvedilol per AASLD guidelines as of 2024.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...
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...
In a patient with dysphagia and manometry showing diffuse esophageal spasm or ineffective motility plus positive pH study, how long should GERD be treated before reconsidering the diagnosis of achalasia, and what additional testing should be pursued?
In this case, optimal treatment for GERD (twice daily PPI) should continue for 8 weeks. If symptoms persist, I would first consider repeat reflux testing on PPI to ensure that reflux is well-controlled on optimized therapy. If not, escalation of reflux treatment may be needed. On the other hand, if ...
What is your approach to work up and management of a patient with advanced HIV and poor adherence to therapy presenting with dysphagia and fever?
I would first do an HPI (is the dysphagia for both liquids and solids?), then a quick physical exam, with a full set of vital signs. In terms of basic blood work, I would get a CBC and BMP, liver function tests, a set of blood cultures, a chest x-ray, along with a viral load and CD4 T cell count, wh...
When do you consider de-escalating therapy such as dupilumab in eosinophilic esophagitis?
It is first important to recognize that EoE is a chronic condition. In a patient whose EoE is successfully being treated (whether it be with PPI therapy, swallowed steroids, food elimination, or dupilumab), the disease will invariably become active again over time if therapy is stopped. This is why ...
Do you use lactulose in acute liver failure, particularly in patients on continuous renal replacement therapy (CRRT) for ammonia or toxin clearance?
Generally lactulose should be avoided in the situation given limited benefit as well a tendency for ileus in ALF and potential for lactulose to cause bowel distention.
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...
What is your treatment algorithm for management of retroperitoneal fibrosis that does not respond to high-dose glucocorticoids?
There are a number of caveats to this. Is the retroperitoneal fibrosis biopsy-proven and/or IgG4 disease ruled out? If a case is refractory, I first question whether the diagnosis is correct and will often biopsy in this situation with more than an FNA biopsy. The second question is how long have t...
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...
How do you diagnose and manage suspected opioid-induced esophageal dysfunction?
Patients with opioid-induced esophageal dysfunction have symptoms of most often, chest pain or dysphagia, with manometric findings of EGJ outflow obstruction, type 3 achalasia, or esophageal spasm/hypercontractile/jackhammer esophagus. When manometry suggests EGJOO or type 3 achalasia, in our practi...