Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
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...
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...
Given that cardiovascular disease is the top cause of morbidity/mortality in patients with MASLD, do you perform any additional screening and/or testing for these patients to minimize this impact?
MASLD should likely be thought of as part of a cardiometabolic disease with a wide spectrum of manifestations. I see my clinic as part of this management, but I do not do a complete cardiac assessment routinely on all my patients. I do not do this simply for the challenge of addressing all these iss...
Do you have any specific recommendations to prevent large fluctuations in sodium levels during a colonoscopy prep in patients with central diabetes insipidus on DDAVP?
Interesting, I have just received a message from a patient in this very same situation. I am not aware of any specific literature on this. In absence of such data, I usually recommend remaining on the same desmopressin dose and obeying to thirst, as I worry about hyponatremia that may be caused by a...
How do you approach the decision to repeat small-bowel biopsies in a patient with persistent gastrointestinal symptoms, like abdominal pain and diarrhea, when prior biopsies performed years earlier were normal?”
I typically do not repeat small bowel biopsies IF the symptoms have not changed in intensity or frequency. Repeat endoscopic evaluation and biopsies are done in patients with persistent GI symptoms if any changes have occurred: these may include significant worsening of symptoms, of symptoms occurri...
Do you routinely check vitamin K levels in post-bariatric surgery patients?
Vitamin K levels are not checked routinely in post-bariatric surgery patients. Deficiency of this vitamin is very uncommon in patients who have undergone a sleeve gastrectomy and even with Roux-en-Y gastric bypass. There is more potential for deficiency in patients who have had biliopancreatic diver...
What Barrett's Esophagus screening protocol do you follow for patients with scleroderma given the increased risk of reflux and esophageal stasis?
This is an excellent question and is probably also relevant to mixed connective tissue disorder (MCTD) and overlap syndromes. My answer is a poor one - to my knowledge, we just do not have the data to guide us. I would certainly be more vigilant, but do not have a set protocol other than that for BE...