Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
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 ...
How do you approach GI prophylaxis (e.g., PPIs, H2 blockers) in patients on long-term NSAIDs?
Risk analysis is at the heart of all therapies that we prescribe for our patients. Patients on long-term daily NSAIDS are at higher risk for GI symptoms, bleeding, and perforations. These risks can be between 2-4%/per year, and vary based on risk factors such as age, general health, cigarettes, prop...
Does hepatitis B vaccination reduce the risk of HBV reactivation associated with immunosuppressive therapy?
Hepatitis B reactivation is a critical concern when patients are undergoing immunosuppressive therapy, often described as 'deadly but preventable.' Screening for HBV is strongly advised before initiating biologic therapies, targeted synthetic therapies, or high-dose immunosuppression, including HBsA...
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...