Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
Do you have concerns with the use of oral contraceptives in patients on JAK inhibitors given the black box warning for thromboembolic events?
I would be concerned with the use of estrogen-containing OC especially in patients who are smokers, obese, and/or with a strong family history of CV disease. However, I know many rheumatologists who would still cautiously prescribe JAK inhibitors to these patients, particularly in the absence of add...
How would you approach asymptomatic hepatic sarcoid?
Hepatic involvement in sarcoidosis is very common. In old autopsy series, as many as 70% of unselected cases of sarcoidosis were found to have granulomatous inflammation in the liver. Today, many possible cases are identified incidentally by more advanced diagnostic testing techniques such as PET sc...
Do you recommend probiotics to patients receiving pelvic radiotherapy?
I have not routinely recommended a probiotic to patients receiving abdominal or pelvic radiation but I did learn early on in my career to suggest it if they continued to have symptoms beyond the usual 2 weeks following radiation and found that it often helped a great deal. I have no idea which is th...
How would you approach management of a patient with a medium-to-large vessel vasculitis who developed perforation of the stomach and colon on steroids and cyclophosphamide?
The answer to this question is complex as will depend on the most likely option for the etiology of the perforation and the nature of the underlying vasculitis. If the perforation is felt to be because of vasculitic activity then the decision could be whether to continue the current therapy (not eno...
Do you have a preference between Quantiferon Gold and T-spot TB for screening in patients starting immunosuppressive agents?
TSpot testing has better performance than Quantiferon Gold in patients with low lymphocyte levels, and/or on glucocorticoids (especially moderate to high doses). This is partially related to the way the essay is performed, and as such the Tspot is much less likely to result in an indeterminate or fa...
Would you consider rituximab in a patient with severe GI dysmotility caused by scleroderma?
Severe GI dysmotility due to scleroderma remains refractory to most therapies. The rationale for recommending rituximab (RTX) in this setting is based on its use in rare cases of autoimmune gastrointestinal dysmotility syndrome (AGID) that appear to have a paraneoplastic basis. There are scattered c...
How would you approach additional workup and management of a patient with active Crohn’s disease, who has multiple lung and brain nodules, with lung pathology demonstrating necrotizing granulomatous inflammation and brain biopsy with granulomatous inflammation and medium-large vessel vasculitis?
This is a great question and a challenging case. Further workup would depend on the clinical presentation and the risk factors of this particular patient, however, I will outline some broad considerations centered around questions I would consider in a similar case. Has Crohn's disease been definit...
Would you treat an unresectable MSI-H colon cancer patient with persistent hepatitis C with immunotherapy?
Great question.There are two questions here:Question 1. Should we treat an unresectable MSI-H colon cancer patient with immunotherapy? The answer is yes, based on the data we have from metastatic disease trials such as KEYNOTE-177 and CheckMate 142 studies. We can also use the phase 2 study data fro...
How do you approach management of patients with active RA and recurrent non-severe C.diff?
I think the question here is why the patient is experiencing recurrent C.diff. Is it true recurrence or it never fully clears? Any IgA deficiency? CVID? I would do an immune deficiency work up- complements, immunoglobulines and flowcytometry, response to pneumococcal vaccine. In parallel to the wo...
In patients with HCC and asymptomatic but endoscopically visible varices, how long do you wait to start bevacizumab after banding?
That is an excellent question and one that does not have a clear answer to date. In these situations, timing of bevacizumab initiation depends on the patient's risk of bleeding and often is a discussion between oncology and a skilled endoscopist. We typically wait ~3-4 weeks after an intervention fo...