Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
How would you approach the treatment of an SLE patient with refractory mucocutaneous ulcerations and lichenoid skin eruption despite treatment with MMF, Aza, Benlysta, Saphnelo, Rituximab, and JAK inhibitors?
This is an interesting case and the co-occurrence of SLE and Crohn's disease is rare but not unprecedented. The first issue is if the mucocutaneous lesions are related to SLE or the IBD and oral lesions are well described in Crohn's disease. Second, although cutaneous manifestations of Crohn's disea...
Is there a risk of hepatitis C activation with rituximab in a patient who has a history of HCV treated with antivirals and who is in sustained viral response?
In general, the risk of HCV flare with immunosuppression in general including rituximab must be viewed as minimal for those who have achieved a sustained virologic response (Undetectable HCV RNA ≥12 weeks after treatment completion) and does not influence my therapeutic decision-making if the patien...
Do you routinely start anticoagulation for a patient with newly diagnosed hepatocellular carcinoma presenting with a portal venous thrombosis?
No. Anti-coagulation is generally not indicated. Anti-coagulation is usually only indicated for acute PVT causing symptoms. This is more common with underlying thrombophilia. PVT is very common in cirrhosis and anti-coagulation is not required. PV thrombus from tumor similarly is common and anti-coa...
How do you counsel patients who experience diarrhea from mycophenolate mofetil (Cellcept)?
I have them stop the drug, and when their bowels are back to normal (usually just a couple of days), I resume with 1 tablet bid of mycophenolate mofetil (MMF, CellCept), then a few days later go up to 1 tab tid, a few days later 2 tabs bid... etc. I instruct them to go down to the most recent dose ...
How do you approach managing nausea and GI side effects when initiating methotrexate?
There are several strategies to minimize nausea and gastrointestinal symptoms with the use of methotrexate. The medication can be taken with food, just not with caffeine. The dose can be split throughout the day it is taken such as half the dose in the morning and the other half in the evening. The ...
What is your approach to secondary prophylaxis for C difficile infection during concomitant antibiotic use in a patient with a history of C difficile infection?
We have been restricting secondary prophylaxis to those patients with severe protein malnutrition, receiving immunosuppressive chemotherapy, generally at the extremes of age who require unavoidable systemic antibiotics that cannot be withdrawn. Based on the 2024 paper by Ronza Najjar-Debbiny et al.,...
Does pyloric manometry help guide your choice of G-POEM vs gastric electrical stimulation in the treatment of gastroparesis?
Data indicates that diabetics with predominant vomiting are more likely to respond to both pharmacologic and non-pharmacologic interventions. In contrast, patients experiencing predominant pain tend to show poor responses to all forms of treatment. Studies have shown that pyloric distensibility and ...
Is there a particular prokinetic agent that you recommend if a patient has failed both PPI and TCA in the treatment of suspected functional dyspepsia?
In general, the evidence to support the use of prokinetics in functional dyspepsia (FD) is not strong. The rationale for using a prokinetic agent for FD is to improve gastric emptying time in the subset (about ¼) of patients who delayed gastric emptying which is usually mild. The three prokinetic ag...
How often would you perform an upper endoscopy on an individual with chronic gastritis and previously eradicated H pylori with respect to risk of gastric malignancy?
Endoscopic surveillance of patients with chronic gastritis and previously eradicated Helicobacter pylori (H. pylori) would primarily hinge on endoscopic/histologic features on index endoscopy.Endoscopically and histologically, the presence and extent/distribution of gastric pre-neoplastic lesions no...
For palliation of gastric bleeding due to malignancy, is a G-tube a contraindication for RT?
I would not change my approach because of a G-tube and I base my dose/fractionation largely on performance status. This recent systematic review is helpful and highlights that a low BED regimen is typically adequate for effective palliation (Tey et al., PMID 28445941).