Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
How do you decide between anticoagulation or portal vein recanalization in a patient with portal vein thrombosis?
It depends on cirrhotic vs non-cirrhotic. For cirrhotic, best to reference the AASLD 2020 guidance here - Northup et al., PMID 33219529.For non-cirrhotic: important to determine the etiology as well as evaluate for a hypercoagulable state, including checking for JAK2 and CALR.If acute and non-occlus...
How do you approach the treatment of reflux hypersensitivity in patients on PPI therapy?
Reflux hypersensitivity is defined by typical reflux symptoms with normal endoscopy and normal esophageal acid exposure, but positive symptom association with physiologic reflux events on pH testing. Because acid exposure is normal, escalating PPI therapy is usually not beneficial, and treatment ins...
Do you recommend, based on current evidence, avoiding antimotility agents in patients with non-fulminant C. difficile infection who have no evidence of ileus?
I generally avoid their use based on the notions that diarrhea may contribute to the elimination of non-invasive GI pathogens and that impairment of intestinal motility could increase the risk of complications, such as toxic megacolon.The data and recommendations have not progressed beyond the follo...
What patient characteristics guide the selection of a step-up versus a step-down elimination diet strategy in the management of eosinophilic esophagitis?
It is a shared decision making between the Physician and the patient. The step-up approach requires fewer endoscopies and may be better tolerated and accepted by the patient. But again a detailed discussion with the patient is needed for any kind of diet strategy to work.
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 take any special considerations for a patient with ESKD who has an ileostomy/colostomy and wishes to start peritoneal dialysis?
My special considerations are to probably avoid PD. But it depends on what the surgical history was for that ileostomy or colostomy, e.g., there may be a lot of scar tissue. When PD works (flows easily in and out), it works; when it doesn',t it doesn't and if doesn't it usually doesn't get better (4...
Is routine surveillance with periodic barium esophagram or endoscopic reassessment indicated in asymptomatic patients more than 20 years after Heller myotomy for achalasia?
While the most recent guidelines from Vaezi et al., PMID 32773454, recommend against routine endoscopic surveillance for esophageal carcinoma in patients with achalasia, they also acknowledge that many experts do favor endoscopic or radiographic surveillance at an interval of ~ every 3 years, if the...
In what clinical scenario would you consider the use of budesonide over prednisone as part of the pharmacologic management of autoimmune hepatitis?
Primarily in patients where the side effects of prednisone will or are too difficult to tolerate (diabetics, weight gain, metabolic syndrome, psychiatric disease, etc). I like to try prednisone first because of its ability to elucidate a biochemical response, fairly rapidly, so we know what we are d...
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...
How do you further workup and treat a patient with nausea and weight loss found to have granulomatous gastritis on endoscopic biopsies with a negative workup for sarcoidosis or Crohn's disease?
Its a good question and challenging scenario. It would be helpful to know a few more details. What was the endoscopic appearance of the stomach, and what symptoms triggered the work up - just nausea and weight loss? How much was the weight loss? How thorough was the work up for Crohn's disease? I as...