Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
What factors into your choice to use craving-related medications (e.g., baclofen, naltrexone, acamprosate, etc.) in the management of alcohol use disorder?
When I discuss starting medications of alcohol use disorder (MAUD), we discuss reducing alcohol cravings, thereby reducing overall intake with the ultimate goal of abstinence with adjunctive psychotherapy if necessary. The options currently available in the market are naltrexone oral and intramuscul...
How do you incorporate other pharmacologic bariatric/appetite suppressants in the context of their clinical care plan for MASLD?
Patients with MASLD have different risk factors and drivers of disease (obesity, diabetes, eating disorders, etc). I lend personalized and individualized care when developing a care plan for patients with MASLD, including the risks, benefits, and alternatives to bariatric surgery (for those patients...
How does presence of clinically significant portal hypertension change patient prognosis in MASLD?
The presence of CSPH based on HVPG or the Baveno criteria (LSM on VCTE + platelet count) indicates higher chances of decompensation. Data from several clinical trials showed that higher VCTE LSM and lower platelet count are associated with higher annual decompensating event rates. Patients with MASH...
When would you consider use of EUS guided liver biopsy over percutaneous and/or transjugular?
If data (labs, imaging) are not entirely compelling for a primary parenchymal or biliary issue, then EUS liver biopsy can be an efficient approach in addition to ERCP (saving the need for separate biopsy in the event that ERCP is non diagnostic).
Do you recommend CBD cessation prior to screening of liver enzymes?
CBD increases liver enzymes. In a study, it took 1-2 weeks to normalize after cessation. Would recommend ideally 2 weeks, but a minimum of 1 week to remove the noise caused by CBD that may lead to an extensive and possibly unnecessary workup.
How would you manage long-segment Barrett's esophagus with both LGD and HGD that has failed to respond to RFA, cryoablation, or even Nissen fundoplication for large hiatal hernia?
ESD/multifocal EMR followed by may be a great option to assess T-stage/rule out occult esophageal cancer. However, the challenge with a large hiatal hernia is ongoing severe GERD and persistent esophagitis. This is a known risk factor for lack of response to endoscopic ablative and resection therapi...
When giving albumin challenge, for acute kidney injury with suspected hepatorenal syndrome, do you administer a single dose daily or split the dose of albumin?
The main concern about albumin infusions is the potential risk for pulmonary edema (China et al., PMID 33657293). Therefore, I prefer to have albumin administered in divided doses of 25 grams at a time with a max daily dose of up to 100 grams, and I tend to stop IV albumin if the serum albumin level...
Do you feel there is a role for triple-phase budesonide in the management of patients with celiac disease who refuse to follow a gluten free diet?
I do not believe it does. Budesonide is useful for acute gluten exposures and type 1 RCD but will not correct the inflammatory cascade associated with chronic gluten exposure and has significant side effects with long term use.
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.