Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
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...
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...
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 routinely perform serologic testing for systemic sclerosis when absent contractility is identified on high-resolution manometry?
This is a good question. The first thing to consider is the LES pressure. If a patient has elevated LES relaxation pressure on high-resolution esophageal manometry, in combination with absent contractility, then this would be concerning for achalasia type 1 (especially when a patient also has delaye...
How do you counsel patients on the use of compounded weight loss medications?
It is a difficult question that is being asked more frequently, recently, because of the shortage of these drugs. I handle it the same way that I used to handle when patients asked about the use of herbs as food supplements. The important fact is that we don't know the reliability of these products....
How many days prior to elective major surgery do you recommend holding oral GLP 1 R agonist therapy?
Zero. Or, I suppose, if you're having surgery early in the morning, one.This has gone back and forth, but the most recent guidance from the ASA (with other societies concurring) has been that most patients can continue their GLP medications as normal preoperatively, with higher-risk people being rec...
Do you avoid terlipressin for patients with hepatorenal syndrome who have an elevated bilirubin level?
The CONFIRM trial excluded patients with Grade 3 acute on chronic liver failure (due to increased risk of pulmonary complications). There have also been concerns raised that using terlipressin on liver transplant candidates might improve their MELD score enough to jeopardize their spot on the waitin...
How do people approach non-HIV patients with hepatitis B, a negative Hepatitis B E antigen, normal LFTs and relatively low HBV DNA between 2000-20000?
Treatment of chronic Hep B is recommended to prevent maternal-fetal transmission, reactivation during chemotherapy, recurrence after liver transplantation, and in patients with decompensated cirrhosis. Treatment has been shown to reverse fibrosis and cirrhosis. Specifically referring to the above sc...
Would you start a biologic without a tissue diagnosis in a young male presenting with recurrent small bowel obstruction and MRE showing distal ileitis, which was unable to be reached despite repeat colonoscopy?
Thank you for your question. Not sure what “young” is, but in the differential are lymphoma and an inflamed Meckel’s diverticulum. You absolutely need tissue before you commit him to a biologic. Steroids can help with a lot of different things and should not be considered a diagnostic criterion for ...