Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
How do you decide which GLP-1s to prescribe for obesity?
Unfortunately, it is the insurance companies who are making the decisions about which GLP-1 I can use, if at all. If insurance is not an issue, I will usually choose Zepbound over Wegovy due to its better efficacy (21% loss in studies vs 15%) and better tolerability. However, if patients are paying ...
Do you routinely recommend diagnostic endoscopy for patients with persistent enterococcus bacteremia despite receiving adequate antimicrobial therapy and no clear nidus?
It depends. Did you do an echocardiogram to rule out endocarditis? Urine cultures were negative? Gallbladder ultrasound was negative? CT of the abdomen and pelvis with contrast was negative?Any other symptomatology that accompanied the recurrent episodes of enterococcus bacteremia that could help us...
What is your preferred management for large esophageal varices with red wale marks found on screening EGD in a patient with decompensated cirrhosis, no prior GI bleeding, and good adherence to medical care?
You're describing high-risk varices, which need to be treated somehow. Guidelines do suggest NSBB and banding as an alternative if patients can't tolerate NSBB, so if you feel this patient may not be able to undergo subsequent EGDs every 2-4 weeks until eradicated, then suggest NSBB.
What non-variceal EGD findings, if any, deter you from using atezo/bev in patients with advanced HCC?
I would discuss the severity and risk of bleeding with the endoscopy team and start beta blockers as indicated before starting anti-angiogenesis therapy.
In patients who have failed 5-ASA and have moderate to severe UC, do you utilize 5-ASA as an adjunct, especially rectal therapy?
Good question. There are two separate questions here. The first is regarding oral 5-ASA therapy. In patients who require initiation of advanced therapy for control of their ulcerative colitis after failing 5-ASA, both the AGA and ACG guidelines for moderate to severe UC recommend not continuing 5-AS...
Should all patients diagnosed with B12 deficiency get a baseline EGD?
It is important to determine the cause of B12 deficiency. The majority of cases are due to pernicious anemia (atrophic gastritis and lack of intrinsic factor), I presume this question relates to that group. If there is another cause such as intestinal malabsorption or bacterial overgrowth, this does...
How do you sequence antiviral therapy and cancer-directed therapy in a newly diagnosed patient with hepatocellular carcinoma and incidentally found hepatitis C?
According to the recent publication by Cabibbo G, et at, J. Hepatol. 2019, 71, 265–273, yes direct-acting antivirals after successful treatment of early hepatocellular carcinoma improves survival in HCV-cirrhotic patients. No such data or evidence for advanced disease though. in that case, antiviral...
Which patients with cirrhosis and portal hypertension are ideal candidates to undergo TIPS to reduce perioperative risk in anticipation of an elective surgery?
A pre-operatively placed TIPS may have a role in preventing hepatic decompensation and post-surgical complications in carefully selected patients undergoing elective abdominal surgery. The data to support TIPS pre-operatively is limited, given the varying surgical contexts and the generally poor pro...
What is your approach to the management of post-TIPS hepatic encephalopathy?
In general, this will depend on if HE is provoked or unprovoked. Provoking factors such as infection, dehydration, medications (sedatives) or GI bleeding are reversible and often do not require aggressive HE treatment when the underlying trigger is removed. It may be reasonable to consider lactulose...
What is your approach to choosing a particular advanced therapy based on patient or disease factors when initiating treatment for moderate-severe IBD?
The selection is based less on relative efficacy and safety (aside from JAKs) and more on the patient: Age, gender, family history, and co-morbidities. Younger males: more concern regarding lymphoma with thiopurines. Young women: If contemplating pregnancy would consider biologics vs small molecule...