Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
Is there a role for checking calprotectin, or other markers of inflammation, in decision making or monitoring in patients undergoing abdominopelvic radiotherapy with history of IBD?
The fecal calprotectin is neither sensitive nor specific enough to determine the protocol for radiotherapy. In fact, the very disease requiring the radiation may contribute to the results! If you need to know the condition of the rectosigmoid, a flexible sigmoidoscopy should be your best bet.
Would you ever consider switching a patient with an LVAD from warfarin to Eliquis, such as in the setting of recurrent GI bleeds?
In general, warfarin remains the agent of choice in VAD patients. However, in patients with INR non-adherence or recurrent GI bleeds, it is an option. In this situation, ensure that GI bleeding is stopped and start 2-3 days after warfarin is stopped. Monitoring with anti-factor Xa monitoring can be ...
Should an individual who received the purified protein Hepatitis B vaccine in 1985 receive a booster or have antibody titers checked?
I recommend you ask yourself two questions. How likely has this individual lost humoral immunity? Did they receive B cell deplaning chemotherapy or have CLL, etc? How likely is the individual to be re-exposed? If the answer to both is low, re-vaccination probably provides no benefit.
How do you decide between anticoagulation or portal vein recanalization in a patient with portal vein thrombosis?
It depends on cirrhotic vs non-cirrhotic. For cirrhotic, best to reference the AASLD 2020 guidance here - Northup et al., PMID 33219529.For non-cirrhotic: important to determine the etiology as well as evaluate for a hypercoagulable state, including checking for JAK2 and CALR.If acute and non-occlus...
What is your experience with transesophageal lung mass biopsies?
Thoracic lesions requiring FNA in the mediastinum are often best approached with EUS–FNA, as the sedation and airway management are less complex than the EBUS, and the needle does not need to break through cartilage rings to access the lesion. On the other hand, a lung mass would require the needle ...
In a patient with Zieve's Syndrome and alcohol related cirrhosis which antibiotic regimen is safe to treat H. pylori?
I am not concerned about a cirrhotic patient receiving a fluoroquinolone, macrolide, metronidazole, or doxycycline. The drug insert labels do not raise any particular concerns for these drugs’ use, even in Child Pugh class C cirrhosis. Yes, there is a theoretical potential for overdosing patients on...
What is your approach to isolated alkaline phosphatase without other laboratory abnormalities?
Assuming none of the other LFTs are abnormal, I would get a GGT. If GGT is elevated --> likely a hepatobiliary issue. Would consider age, medical history, and risk factors. If persistently elevated, could consider RUQ US + MRCP. Conditions like PSC or PBC are frequently discovered due to asymptomati...
At what BMI or waist-circumference threshold do you opt to move from Fibroscan to other NILDA for fibrosis assessment?
The XL-validation study found a liver stiffness measurement (LSM) failure of 1% for the XL and 16% for the M probe, in patients with a BMI of 28 or above. In people with a BMI of 40 or above, the XL-probe failure was 5%, and the best predictor of failure was a skin-to-capsule distance (SCD) ≥25 mm (...
If you do not have easy access to shear wave elastography (aka Fibroscan), what do you recommend for non-invasive tests to determine if a MASLD patient has clinically significant portal hypertension and risk-stratify them?
Great question. I do magnetic resonance elastography (MRE), and if not possible, shear wave elastography (SWE). If I have access to only blood-based non-invasive liver disease assessment (NILDA), will then order enhanced liver fibrosis (ELF). However, for clinically significant portal hypertension (...
In patients with Met-ALD, would you still offer the same therapeutic/pharmacologic treatments (ex: GIP/GLP-1 agonists, Resmetirom, ex) for management of their disease as in a "pure" MASLD patient?
We would need to differentiate which is the bigger driver force (alcohol vs metabolic dysfunction) to determine the likelihood that MASH treatment would be effective. Alcohol use can be objectively quantified by phosphatidylethanol, which is a test commonly available in health systems with a liver t...