Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
Is there a role for use of dupilumab for hypereosinophilic GI disorders distal to the esophagus?
No definitive studies performed yet and no FDA approval regarding using Dupilumab for EoG; however, in my opinion, I do believe that Dupilumab may be an effective treatment for some eosinophilic disorders beyond the esophagus.
Is there a role for anti-IL5 therapy in the treatment of EoE?
When looking at the use of IL-5 pathway drugs such as mepolizumab, reslizumab, and benralizumab in the treatment of eosinophilic esophagitis (EoE) studies to date have not demonstrated efficacy in terms of symptomatic improvement as related to the use of these series of medications. Each of these me...
How would you manage a patient with highly active ankylosing spondylitis, iritis and Crohn’s, controlled with weekly adalimumab with co-morbid IgG4RD and intolerance of azathioprine due to elevated LFTs?
There is not a known association between IgG4-RD and IBD or spondyloarthritis. Given that these are rare diseases, it is important to ensure diagnostic accuracy, as the combination of these diseases would be unusual, though not impossible. There are two types of autoimmune pancreatitis: type 1 (IgG4...
What is your treatment approach for a patient with metastatic hepatocellular carcinoma with Child's Pugh B cirrhosis?
Child Pugh B cirrhosis is a spectrum of disease, and requires careful consideration of the underlying cause of the cirrhosis as well as the potential impact of cancer therapy. As @Dr. First Last pointed out, there is data for sorafenib in this patient population, demonstrating a similar relative ben...
Would you intensify therapy in IgG4 related disease based solely on a persistently significantly elevated IgG4 level when all disease manifestations and inflammatory markers have normalized?
While a perfect biomarker does not exist in IgG4-related disease (IgG4-RD), patients who have elevated serum IgG4 concentrations at baseline typically demonstrate a significant reduction of IgG4 concentrations after treatment and with improved disease activity. In patients treated with rituximab, on...
What initial workup do you perform when there is a concern for porphyria?
This is a terrific question. But a broad question. Porphyria refers to a defect in heme biosynthesis leading to the accumulation of porphyrins and porphyrin precursors. We should remember that there are three general categories of porphyria based on clinical manifestations: acute hepatic porphyria (...
How do you monitor patients with incidentally found high titer anti-smooth muscle antibodies without stigmata of liver disease?
I have quite a few SLE patients with ASMA who do not have any signs of hepatic disease (though I did not do bxs in those with normal hepatic transaminases). They are very common in the general population. I have down in my notes a prevalence of 16%. However, there are studies showing prevalences as...
What treatments have you found most effective for cholestatic pruritus?
My experience is mainly in Sjogren's or Sjogren's with PBC, ursodiol has been effective. Occasionally, I have used hydroxyzine or H1+H2 blockers. In Sjogren's where the skin biopsy has shown significant lymphocytic infiltration, mycophenolate or a calcineurin inhibitor trial has lead to the resoluti...
How do you approach the treatment of microscopic colitis?
If there is a temporal association between starting a drug like NSAIDs, PPI, SSRI, statin in the onset of diarrhea deny would stop the medication before beginning pharmacological therapy for microscopic colitis. If there is no potential drug trigger, and I stratify my treatment based on severity of ...
How long should surgery be delayed in a patient with localized, resectable pancreatic cancer who developed acute pancreatitis following EUS guided biopsy?
This is a great question, and the answer is yes, it should be delayed to avoid surgical complications, healing, etc. In such scenarios, surgery might be delayed up to 2 months or longer even, depending on the time to recovery. In our practice, we employ a neoadjuvant approach for these patients and ...