Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
For remote liver transplant recipients back under the care of a community gastroenterologist (or PCP), what should be the approach to new liver enzyme elevations?
Elevated liver enzymes in post-transplant patients who live far from their transplant center are a common challenging issue. Many factors will influence your recommendation to the local physician: height of enzyme elevation, cholestatic, hepatitic, or mixed profile, and associated symptoms (pain, fe...
How do you decide which patients with upper GI bleeds should be monitored on telemetry?
Telemetry use has some standard indications in GI bleeding, specifically for patients with hemodynamic instability and significant cardiac comorbidities. Such situations include unresolved hypotension, >4 units transfused, known arrhythmia, and severe HFrEF. In these cases, I’m worried about someone...
How do you balance the need for diuretics from a volume perspective (Ex: ascites, edema) in decompensated cirrhotic patients and progressive renal dysfunction?
There is no discrete answer to this question. Much depends on the overall goal of care. For a transplant candidate, higher creatinine may be needed for transplant access and be tolerated, but risk need for post-transplant RRT. If goals are palliative, symptom control supersedes renal function.
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...
In a patient with low (or normal) BMI but findings of steatosis on imaging, no cardiometabolic comorbidities, and very elevated CAP scores, what are your next diagnostic and therapeutic steps to identify the cause of their steatosis and subsequent management?
In addition to knowing the level of steatosis, liver stiffness values would be of most interest. Alcohol use should stop if there is any level of fibrosis. Lifestyle modifications (dietary/exercise) should be part of recommendations, but with a goal of around 5 % weight loss. If they have F2-3 fibro...
In patients with GERD, when should Baclofen or alginate-based therapies be considered, and which patient characteristics warrant caution when using these treatments?
Baclofen and alginate-based therapies are adjunctive, phenotype-directed options for actionable GERD symptoms refractory to optimized proton pump inhibitor therapy. Baclofen reduces transient lower esophageal sphincter relaxations and is most effective in regurgitation or belching predominant phenot...
How do you manage/treat acute radiation-induced enteritis?
I have no problem with the excellent comments already made. However, I think it is important to add some comments. First - one needs to be sure that the patient truly has radiation enteritis. Many patients receiving abdominal radiation therapy have other issues that need to be explored first. For ex...
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...
Which patients, if any, do you revert back to ultrasound screening for HCC after prior diagnosis/definitive treatment of HCC?
I don't revert back to U/S for these patients ever. It's not dissimilar from colorectal cancer screening - once you have colon cancer, it's not appropriate to use iFOBT or stool DNA screening anymore - it's lifelong colonoscopy screening. Likewise, for HCC, I continue to use AFP plus cross-sectional...
How would you approach the evaluation of a patient with decompensated cirrhosis, suspect to be due to alcohol, who is not a liver transplant candidate with iron studies showing elevated saturation and ferritin over 1000?
The finding of elevated iron saturation (I suspect means above 55%) and high ferritin raises the diagnosis of true iron overload. Certainly, a Ferritin level above 1000, when the patient is not actively drinking, is consistent with cirrhosis. So, I would start phlebotomies if the Hgb >11-12 g/dL all...