Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
How do you approach the continued use of TNF inhibitors in a patient with inflammatory arthritis who develops a positive dsDNA without clinical evidence of drug-induced lupus?
This is a good question and more common than we think. Most of us are not routinely drawing dsDNA ab when the patient does not have symptoms; some reviews suggest up to 29% (see review below). I have seen this, however, and continued medication with monitoring (following dsDNA ab levels with C3 and ...
How do you select systemic therapy for advanced HCC patients with portal vein thrombosis?
Generally, patients with advanced portal vein thrombosis (PVT) are excluded from studies, generally because it can impact the patient’s other hepatic indices. Extensive thrombosis may jeopardize blood flow in the liver, cause elevated bilirubin, reduced albumin, and increased ascites, i.e. lead to C...
How do you manage dyschezia and tenesmus following TNT with short course RT?
Specifically for the management of moderate to severe tenesmus and pelvic pain/cramping, I’ve found that combinations of steroids, bentyl, and gabapentin are very effective. Another consideration, if sequencing short course RT prior to chemotherapy, is to delay chemotherapy for 2-4 weeks after short...
Do you counsel patients with an ileostomy about significant diarrhea when treating the pelvis with radiotherapy?
For patients with an ileostomy, they should be told that they are expecting to have an ileostomy output of approximately 1 to 1.5 L per day immediately after recovery from surgery. However, the output may decrease over time.If a large amount of small bowel is in the pelvic radiation field and/or the...
How do you manage calcium and vitamin D replacement in scleroderma and myositis patients with dysphagia and malabsorption?
Dietary calcium is a good choice. I recommended that my patients with dysphasia caused by scleroderma drink 2-3 glasses of skim milk daily. 8 ounces contain 300 mg of calcium which is highly bioavailable. It also provides a good source of whey protein that contains all the essential amino acids. Ano...
How would you treat a patient with recurrent metastatic HCC 6 years after liver transplant for HCC?
Sadly, I have seen recurrence as far out as 10 years in these situations. Given the high risk of organ rejection (some literature report up to 40%) with immunotherapy and the lack of prospective data, I typically start patients with TKI such as lenvatinib or sorafenib depending on the provider's pre...
In patients chronically treated for Wilson's disease with trientine hydrochloride (Syprine®), would you expect development of neurologic symptoms?
On trientine, patients with asymptomatic WD should remain asymptomatic. The onset of neurological symptoms in someone with only hepatic disease on maintenance therapy represents treatment failure. Precise rates and etiologies of treatment failure are lacking, though one cohort review documented 19% ...
What is your approach to management of elevated liver enzymes in patients who recently started treatment with tocilizumab?
This is an important concept because anyone using tocilizumab will eventually wrestle with this question. The question, though, does not tell you whether this is the first time a practitioner sees the liver enzyme elevation, or how high the liver enzymes rose. Since everyone should have had a lipid ...
How do you counsel patients about the malignancy risk associated with azathioprine?
Malignancy with the use of AZA (Imuran) was documented many decades ago in a renal transplant population, not in rheumatoid patients. Are they equivalent? Overall I consider Imuran a pretty safe DMARD. In fact, it can be used in pregnant patients with lupus, with mothers and babies doing just fine.
How would you treat a patient with metastatic cancer with a lesion invading the small bowel causing bleeding and potential obstruction?
Radiation reliably relieves bleeding but typically does not relieve obstruction. It may be worth trying if there is not an impending obstruction. We have plenty of experience in rectal cancer that this is a successful strategy. Since it's located in the small bowel, I would use standard fractionatio...