Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
What is your strategy in the management of patients with autoimmune hepatitis who failed azathioprine therapy and what parameters do you monitor with what frequency?
Great question. Around 10% of autoimmune hepatitis cases don't respond to azathioprine (AZA) and 15% may have an incomplete response to AZA. These patients require second-line therapy. Before initiating second-line therapy, it's important to exclude non-adherence. Mycophenolate Mofetil (MMF) is the ...
What factors make you consider an EUS before embarking on an ERCP for concern for type 1 Sphincter of Oddi dysfunction, (appropriate biliary symptoms, dilatation of ducts with no stones on MRCP, and liver labs suggestive of cholestasis)?
When clinical presentation is not typical for SOD and imaging raises the question of an anatomical/structural cause, or history of idiopathic recurrent pancreatitis, a diagnostic EUS may be helpful in this context. If the clinical presentation with LFTs and imaging meets criteria for type 1 SOD, EUS...
How do you decide when to use acid-suppressive medications for GI prophylaxis when patients are on prolonged corticosteroid therapy?
Consideration of risk factors is important. Routinely, someone without these risk factors, and if getting a short burst of steroids, the GI prophylaxis is not given. PPIs carry certain risks, including increased risk of C. Diff infection or even pneumonia. So, they should be avoided if not indicated...
Under what circumstances do you give chemotherapy for a nondiagnostic pancreas biopsy that is suspicious for adenocarcinoma?
Assuming it is a localized pancreatic abnormality and no "metastases," I would not give chemotherapy as such. If anything, I would consider surgical removal, which will also give the exact diagnosis. To start, chemotherapy is not curative (maybe if it were a lymphoma!). There may be some way of doin...
What clinical features would raise your suspicion for IgG-4 related disease?
IgG4-related disease can affect multiple organs, leading to varied presentations. In the abdomen, patients can have symptoms secondary to pancreatitis and or biliary obstruction. In the liver, patients can present with a PSC-like picture (jaundice, cholangitis, ductal strictures/dilatation) that, un...
Which GI cancer patients do you use oral contrast in staging CT scans?
We do not use oral contrast for most of our patients and only offer oral contrast CT scans for patients we are concerned about perforation.
In a patient with unresectable HCC who developed immune-related colitis with the first dose of tremelimumab/durvalumab, would you consider continuing durvalumab alone after resolution of the colitis with steroid treatment?
I haven’t seen too many TREMI/DURVA colitis cases, but basing experience off of BOT/BAL, which is notorious for the CTLA-4 inhibitor-related BOT-colitis, as well as some patients who have had IPI/NIVO colitis, or any grade ≥3 event in the combination setting, it’d be reasonable to continue the PD1/P...
What surveillance is recommended for a C1M3 segment of columnar-lined esophageal mucosa with repeated biopsies demonstrating columnar metaplasia but no goblet cells/intestinal metaplasia across multiple endoscopies?
Based on current U.S. guidelines, routine endoscopic surveillance is not recommended for columnar-lined esophagus without intestinal metaplasia (goblet cells). The American Gastroenterological Association (AGA) does not consider this Barrett's esophagus and does not recommend using that term or perf...
For high-risk ulcer bleeding requiring early anticoagulant resumption, what endoscopic/clinical threshold prompts you to add adjunctive prophylactic hemostatic powder specifically to support earlier restart?
If there is a high-risk ulcer, I would treat it as indicated. If, at the end of treatment (whether with injection + thermal therapy/ clips, etc), I am not confident that I rendered effective treatment, then I would apply hemostatic powder.
How do you decide which GLP-1s to prescribe for obesity?
Unfortunately, it is the insurance companies who are making the decisions about which GLP-1 I can use, if at all. If insurance is not an issue, I will usually choose Zepbound over Wegovy due to its better efficacy (21% loss in studies vs 15%) and better tolerability. However, if patients are paying ...