Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
How do you diagnose and manage suspected opioid-induced esophageal dysfunction?
Patients with opioid-induced esophageal dysfunction have symptoms of most often, chest pain or dysphagia, with manometric findings of EGJ outflow obstruction, type 3 achalasia, or esophageal spasm/hypercontractile/jackhammer esophagus. When manometry suggests EGJOO or type 3 achalasia, in our practi...
Would you consider a combination of anti-TNF therapy and azathioprine upfront in a young male with Crohn’s disease considering its risk of lymphoma in the era of several advanced therapies?
Definitely, TNF + IMM hasn’t been beaten in efficacy. If the patient is in clinical and endoscopic remission at 6-12 months with good IFX levels, then they can stop the IMM.
How do you decide when to initiate or restart diuretics in a cirrhotic patient with ascites if they are receiving a therapeutic paracentesis?
This question has two parts, one with a straightforward answer, the other with a much more nuanced answer, if I understand it correctly. Any patient receiving a therapeutic paracentesis should start/restart diuretics afterwards. Per the 2021 AASLD guidelines, one of the statements reads “LVP is the ...
What factors can lead to falsely elevated fibrosis readings on FibroScan (e.g., consuming sugar before the scan)?
I recommend 3 hours of fasting before performing a FibroScan. Liver stiffness may not be equivalent to fibrosis stages in the following conditions: liver congestion (right-sided heart failure, Fontan-associated liver disease), active liver inflammation (alcohol, active viral or autoimmune hepatitis)...
In patients with F2/F3 fibrosis, would you start Resmetirom if they had normal liver enzymes?
Yes, it would be reasonable, especially if you can prove that they still have significant steatosis (such as a CAP of >300 db/m) or active MASH on liver biopsy, as Resmetirom works by directly removing fat from the liver. The lack of liver enzyme elevation is not a reliable sign to rule out steatohe...
What is your preferred management for large esophageal varices with red wale marks found on screening EGD in a patient with decompensated cirrhosis, no prior GI bleeding, and good adherence to medical care?
You're describing high-risk varices, which need to be treated somehow. Guidelines do suggest NSBB and banding as an alternative if patients can't tolerate NSBB, so if you feel this patient may not be able to undergo subsequent EGDs every 2-4 weeks until eradicated, then suggest NSBB.
What non-variceal EGD findings, if any, deter you from using atezo/bev in patients with advanced HCC?
I would discuss the severity and risk of bleeding with the endoscopy team and start beta blockers as indicated before starting anti-angiogenesis therapy.
What is your approach to explaining the role of the microbiome to patients with inflammatory arthritis?
The gut microbiota play a central role in modulating the inflammatory response. This is especially relevant to inflammatory arthritis, where the pathogenesis is quite well understood, especially as it relates to arthritis associated with inflammatory bowel disease. We also know that the diet is the ...
In patients who have failed 5-ASA and have moderate to severe UC, do you utilize 5-ASA as an adjunct, especially rectal therapy?
Good question. There are two separate questions here. The first is regarding oral 5-ASA therapy. In patients who require initiation of advanced therapy for control of their ulcerative colitis after failing 5-ASA, both the AGA and ACG guidelines for moderate to severe UC recommend not continuing 5-AS...
Should all patients diagnosed with B12 deficiency get a baseline EGD?
It is important to determine the cause of B12 deficiency. The majority of cases are due to pernicious anemia (atrophic gastritis and lack of intrinsic factor), I presume this question relates to that group. If there is another cause such as intestinal malabsorption or bacterial overgrowth, this does...