Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
How do you further workup and treat a patient with nausea and weight loss found to have granulomatous gastritis on endoscopic biopsies with a negative workup for sarcoidosis or Crohn's disease?
Its a good question and challenging scenario. It would be helpful to know a few more details. What was the endoscopic appearance of the stomach, and what symptoms triggered the work up - just nausea and weight loss? How much was the weight loss? How thorough was the work up for Crohn's disease? I as...
How do you approach a patient with endoscopic ileitis without typical features of chronicity on histology, who has worsening abdominal pain and increased stool frequency despite a trial of budesonide?
I am not sure, but I will assume "without typical features of chronicity" means it is either normal or acute inflammation. Acute inflammation is either prep effect, exogenous hormones, or NSAIDs, but this is not Crohn's and would be treated as IBS. If normal, then for sure treat as IBS.
How do you manage a patient with dysphagia whose EGD shows mild esophageal rings and furrows, but histology was negative for interepithelial eosinophils?
That is a great question. The question stem gives the impression that the endoscopic appearance is suggestive of eosinophilic esophagitis. A few things to consider: First, I would make sure that the procedure was done off any treatment, especially PPI therapy. Many patients come for endoscopy alread...
What is your endoscopic approach towards laterally spreading colonic lesions that are over 2 cm in size?
Laterally spreading tumors or LSTs can be of the granular or non-granular type, and the former may have surface nodularity (LST-G-N) and the latter may have a depressed center with different risks of occult cancer and submucosal invasion. LSTs of the nongranular with pseudo-depressed (LST-NG-PD) mor...
How do you approach surveillance and repeat biopsies in a patient with a diagnosis of intestinal metaplasia (aka Barrett's esophagus) on pathology who appears to have a regular Z-line or <1 cm of salmon mucosa?
I agree with the other responses to this question. One other aspect that can be tricky in patients where you did not do the index endoscopy is that many patients present with the expectation that they will need further surveillance, or have already been told that they will need surveillance at some ...
What are the target distensibility index and EGJ diameter values on EndoFLIP following peroral endoscopic myotomy (POEM)?
An increase in the intraoperative EGJ-DI following POEM correlates with improved symptomatic response. Persistent DI < 2 is associated with poorer outcomes. When using EndoFlip, our team evaluates patients following POEM by using the 60 mL fill volume and aims for a DI of at least 2.8 and a diameter...
Should asymptomatic esophageal candidiasis identified incidentally on endoscopy be treated?
Yes, in our practice, we do treat asymptomatic esophageal candidiasis when found incidentally on endoscopy. A few things to consider: 1) While patients may be asymptomatic at the time of the endoscopy, untreated disease can lead to the future development of complications/symptoms, such as odynophagi...
What is your approach to perioperative risk stratification and optimization in patients with cirrhosis?
The VOCAL-Penn score is one piece of information that I use for risk stratification in patients with cirrhosis. I usually treat symptomatic decompensated cirrhosis first (hepatic encephalopathy, ascites, hepatic hydrothorax, hepatorenal syndrome, variceal bleeding), because the risk scores usually c...
Do you take any special considerations for a patient with ESKD who has an ileostomy/colostomy and wishes to start peritoneal dialysis?
My special considerations are to probably avoid PD. But it depends on what the surgical history was for that ileostomy or colostomy, e.g., there may be a lot of scar tissue. When PD works (flows easily in and out), it works; when it doesn',t it doesn't and if doesn't it usually doesn't get better (4...
Do you recommend checking anti-drug antibodies for patients on TNF inhibitors?
This is a very good question with direct clinical practice implications. I do not check or follow anti-drug antibodies when using TNF inhibitors for the treatment of rheumatoid arthritis or psoriatic arthritis. There are reports that suggest, on a group level, that these antibodies, if present, impa...