Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
How do you approach screening for inflammatory bowel disease prior to starting IL-17 inhibitors?
IL-17i are now widely used to treat skin psoriasis (PsO), psoriatic arthritis (PsA), and axial spondyloarthritis (SpA). Genetic and epidemiologic studies suggest the coincidence of these diseases and Crohn’s diseases (CD) as they may present concomitantly in the same patient or affect a family membe...
How do you approach relapsed hepatocellular malignant neoplasm NOS after transplant in pediatric or AYA patients?
There exist no standards of care for patients with HCN NOS after front-line therapy has failed. Considerations include response to prior therapy, agents used front-line/not used, sites of disease, surgical options, and molecular findings of the tumor itself. Platinum/anthracycline-based therapy, car...
With what agents can you replace PPIs if they cause thrombocytopenia?
The incidence of PPI-induced thrombocytopenia is very low - and really only reported in case reports. I would suggest ensuring the low platelet count is really from the PPI (in some cases may be reasonable to re-challenge the patient), and not from a more common reason. In a recent case report on La...
How do you approach treatment of metastatic hepatocellular carcinoma in an adolescent?
Clarification - do you mean fibrolamellar carcinoma? Often mistakenly treated or referred to as a HCC variant or as a subset of HCC? Does it have the characteristic DNAj-PRKACA fusion for FLC? Is there underlying liver disease? Or do you mean conventional HCC? (common in older adults with liver dise...
Is there a role for liver transplantation in an initially unresectable HCC with a complete response after bevacizumab-atezolizumab?
I have had one patient who successfully underwent liver transplantation after an excellent response to atezolizumab plus bevacizumab. The patient was young and otherwise healthy. Further, he was taken off treatment and had no recurrence after 2-3 months off immunotherapy before being considered for ...
How would you treat a poorly controlled seronegative RA patient who is steroid dependent and is on azathioprine for autoimmune hepatitis?
I would add a biologic agent, likely a TNF inhibitor or abatacept. As with any patient with active RA, it would be important to add therapy that controls their disease activity, as well as allowing them to reduce or preferentially discontinue steroids. I would avoid other agents with known risk for ...
How do you treat celiac disease associated inflammatory arthritis refractory to gluten free diet?
There is no good evidence based answer to this great question. In general, if celiac patients have persistent symptoms and exam findings of inflammatory arthritis or enthesitis, I offer non-biologic DMARDs depending on the severity of symptoms. If very mild, we can use hydroxychloroquine and escalat...
How would you approach a patient with imaging and labs suggestive of potentially resectable cholangiocarcinoma when several core biopsies reveal bridging fibrosis with no malignant cells?
I believe the first step would be presenting the patient's imaging and case at a multidisciplinary tumor board for input, especially from GI and surgical oncology, ideally at a higher volume center. You don't specify the route of prior biopsies but I am assuming they are percutaneous. Perhaps yield ...
When would you consider rituximab as induction therapy in IgG4-related disease?
This is a great question, especially given concerns around rituximab in the setting of the COVID-19 pandemic. I think it is reasonable to consider starting with steroids monotherapy for non-organ threatening diseases. Rituximab can be added if the patient relapses or if there is a concern for steroi...
When would you consider a workup for C. diff in a patient with diarrhea under-going concurrent chemoradiotherapy for rectal cancer?
Good question – and hard to pinpoint a strict answer. I think any time the diarrhea is out of proportion to expectation (i.e., very early in RT course), clinically significant (dehydration, etc), and not controlled or responding to anti-diarrheal medications, especially in the setting of C. diff ris...