Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
What factors do you consider when a patient with acute severe ulcerative colitis flare responds to inpatient Infliximab, and you are deciding whether to switch to subcutaneous or continue IV maintenance dosing of Infliximab?
Patients admitted with acute severe ulcerative colitis typically have higher drug clearance related to significant fecal loss of infliximab through a highly inflamed colon, leading to low levels and often the need for dose escalation. There have been studies showing that infliximab levels in severe ...
Would you consider Resmetirom in a patient with metabolic risk factors and persistently elevated transaminases despite lifestyle changes, after a negative workup for other liver diseases, with noninvasive testing suggesting minimal fibrosis (F0–F1)?
Resmetirom is only approved for MASH with F2-3 fibrosis, so it will likely not get approved. If there is evidence of continued hepatic steatosis and no other competing etiologies, would continue current lifestyle recommendations and repeat fibroscan, ELF, or MRE in 1 year. If competing etiologies (e...
What is your preferred first-line regimen to treat a severe or fulminant C difficile infection?
IV vancomycin and PO Flagyl are the easiest combination to get for a hospitalized patient. I’ve had much experience with this, and it works very well. IV vancomycin and PO Flagyl as initial treatments in the hospital is my preference. This is before I go onto stronger drugs, with those requiring al...
What is your treatment algorithm for solitary hepatocellular carcinoma, 3-5 cm, non-operative candidate but Child-Turcotte Pugh A/B?
This really boils down to two issues: CTP score and size of the lesion. For patients who are CTPA with a lesion <3 cm, RFA/MWA or SBRT are good options although there is some data from the University of Michigan (Wahl et al., JCO 2014) that lesions > 2 cm are better served with SBRT. For solitary le...
Do 5HT4 agonists such as Metoclopramide actually lead to improvement in symptoms for patients with diabetes related gastroparesis?
Yes, sometimes when the gastroparesis is frequent or the symptoms are tough, I do use Reglan to help. By the time they wind up in the hospital, they are really willing to have me use anything on them that might help. I explain to every patient the side effects of Reglan, including tartive dyskinesia...
What is your approach to liver transplantation candidacy in those with decompensated cirrhosis who have been treated for a solid-organ malignancy, such as oral SCC?
This is an important consideration as patients who receive a solid organ transplantation will be on significant immunosuppression, which can result in significant proliferation of an underlying malignancy and have worse treatment outcomes compared to non-immunosuppressed patients. Furthermore, patie...
What is the role of inebilizumab in the maintenance treatment of IgG4-related disease?
Inebilizumab may play an important role in the maintenance treatment of IgG4-related disease (IgG4-RD), particularly in patients at high risk for relapse. These are typically patients with multi-organ involvement and elevated serum IgG4 levels who initially respond well to corticosteroids but tend t...
Do you routinely give prophylactic antibiotics prior to ERCP for biliary obstruction in light of recent studies suggesting a reduction of periprocedural infection?
I did not use to give antibiotics routinely prior to ERCP, and it seemed post-ERCP antibiotics were given at the discretion of the advanced endoscopist, but the results of this meta-analysis will likely change my practice so that I'll give all patients a dose of Ceftriaxone prior to the procedure to...
Would you consider the use of prophylactic antibiotics in patients admitted with decompensated cirrhosis with AKI with Cr>1.2, with ascitic fluid protein <1.5 without SBP and/or hyponatremia/Bili >3?
Is this in generalized cases or cases of GIB? If GIB, yes, I would consider it. In just generalized cases, there is no real role for empiric antibiotics.
How do you decide between systemic vs. arterially directed therapies in the first line setting for unresectable HCC?
In IMbrave150, 63% of patients treated with atezolizumab/bevacizumab had extrahepatic spread of disease, and my recommendation for patients with extrahepatic involvement is for first line systemic therapy. For patients with unresectable disease without extrahepatic spread, we take a multi-disciplina...