Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
Do you discontinue or adjust azathioprine when a patient develops elevated MCV after starting it?
Great question, with practical implications for the clinic: Azathioprine (AZA) is a prodrug that likely exerts its immunosuppressive effects against B- and T-cell function by interfering with purine metabolism through its metabolites (including 6-MP). Logically, many of the "classic" AZA side effect...
Would you recommend stent placement upfront in a patient with cervical esophageal cancer and a TE fistula?
Malignant TE fistula is a complex problem which is often associated with a poor prognosis. Palliation with stenting can be problematic as the stent can erode and make the fistula larger. This is especially problematic with "kissing" stents in both the esophagus and the airway and/or in the setting o...
Do you consider anti-viral prophylaxis in patients taking JAK inhibitors who have recurrent uncomplicated Zoster infection, but would prefer not changing therapy?
This is a really good question without a clear answer. Patients on JAK inhibitors are not only at increased risk for VZV but also for recurrence. Data from Kevin Winthrop and colleagues examining the tofacitinib database revealed that patients with RA and PSA are at 10 to 20 times increased risk for...
Has pelvic MRI replaced EUS as the standard of care for rectal cancer staging?
I think looking at data both show very similar sensitivity and specificity for staging and is matter of expertise and resources available at the institution.
When do you perform BRAF testing in colon cancer?
I now perform BRAF testing as close to diagnosis of metastatic cancer as possible. While it is not a predictive test, the prognostic value is important. We discuss prognosis with our pancreatic cancer patients differently than our CRC patients. Now, I think we should discuss prognosis differently wi...
When do you perform HER2 testing in patients with colorectal cancer?
HER2 amplification is seen in a small but distinct subset of colorectal cancer. This subset has 2 unique characteristics: They are predominantly RAS wild type tumors. They do not respond to anti-EGFR agents, i.e. HER2 amplification is a negative predictor of anti-EGFR antibody (cetuximab and panitu...
Could a non-cirrhotic patient with a single HCC lesion measuring >5cm who is ineligible for liver transplant by Milan size criteria alone become a candidate if the tumor shrinks after TACE?
While the Mazzaferro (Milan) criteria still represent the primary basis by which HCC candidates for liver transplant are chosen, certain centers such as ours (UCSF) have studied the strategy of expanding eligibility criteria for OLT. This includes both increasing upper tumor size limits, as well as ...
Would you recommend sorafenib as an adjunct to liver targeted therapy in patients with hepatocellular carcinoma who are awaiting liver transplant?
There is not a clearly defined role for adjuvant sorafenib following locoregional therapy for HCC. The two main prospective randomimzed trials that inform this recommendation are:- The SPACE trial (Lencioni et al, J Hepatol 2016) -- no improvement in TTP when DEB-TACE was followed by sorafenib vs pl...
Is it necessary to hold immunotherapy during a 4-6wk steroid taper after resolution of immunotherapy related toxicity?
This is an excellent question. Most of the clinical trials with checkpoint inhibitors required complete taper of steroids prior to rechallenging wtih immunotherapy following toxicity. As we use immunotherapy in the clinic, and have utilized combinations with chemotherapy, including regimens that use...
Are you categorically using lenvatinib over sorafenib for unresectable HCC in the absence of contraindications?
I have done that is recent patients, yes. I am doing it because "on paper" I see better PFS and better ORR, of course in addition to the non-inferiority when compared to sorafenib in the randomized trial that is now published. However, I am building experience with respect to tolerance in my particu...