Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
What prompts you to obtain esophageal biopsies in patients with GERD who have a normal-appearing esophagus on EGD and no dysphagia?
This is a good question. I do not routinely, unless there are other factors that steer me in the direction of eosinophilic esophagitis (EoE), such as a young patient with extraesophageal atopic disorders, where heartburn may be the presenting symptom of EoE.
How do you approach a referral for findings of intestinal metaplasia on a biopsy of an irregular z-line?
It is true that intestinal metaplasia of the GEJ is not Barrett's esophagus but it increases the risk of cancer like it is in the stomach. In the last 5-10 years, it has attracted more attention. Now, pathologists are starting to describe complete vs incomplete intestinal metaplasia. A good study wi...
In patients with GERD, when should Baclofen or alginate-based therapies be considered, and which patient characteristics warrant caution when using these treatments?
Baclofen and alginate-based therapies are adjunctive, phenotype-directed options for actionable GERD symptoms refractory to optimized proton pump inhibitor therapy. Baclofen reduces transient lower esophageal sphincter relaxations and is most effective in regurgitation or belching predominant phenot...
Do you recommend routinely monitoring pancreatic markers such as amylase and lipase while receiving GLP1 R agonist or dual agonist therapies to determine their risk of pancreatitis?
Absolutely not. We know that changes in amylase and lipase levels on these drugs are very common. For example, if you look at the supplementary data across the SUSTAIN series of phase 3 trials with subcutaneous semaglutide, the average person had about a 15-30% rise in their amylase/lipase. Further,...
How would you approach interval worsening of pancreatic fluid collection with the development of "extensive pancreatitis" on imaging without elevated lipase, any abdominal pain, nausea, or vomiting?
Well, naturally, knowing additional details and seeing an image would be important, but based on what I am hearing, I would recommend a few things: If the cross-sectional imaging indicates pancreatic fluid collection, it is important to know when the initial pancreatitis occurred. The more mature th...
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 a patient with intermittent pouchitis who has up to 3 acute pouchitis episodes that respond well to antibiotics, how do you manage leakage of stool, especially at night?
Leakage at night is an expected outcome in a pouch patient. Women who have given birth or older patients who have weaker anal sphincters are susceptible to this. First, make sure they do not have cuffitis or pouchitis. Anorectal manometry will identify this with depressed pressure/tone. A cotton ple...
What vitamins and minerals do you check yearly for patients post gastric bypass surgery?
Following Roux-en-Y gastric bypass it is essential to monitor micronutrients, vitamins, and minerals because malabsorption and long-term complications may occur with improper care. Based on ASMBS 2016 Nutrition Guidelines, AACE/TOS/ASMBS 2019 updates, and Endocrine Society recommendations, here are ...
Do you recommend restarting a GLP-1RA after bariatric surgery if the patient tolerated it before the surgery?
While there are no clear recommendations on whether/when to resume GLP-1 RA after bariatric surgery, current 2025 guideline statements (ASMBS, ADA, AACE, Obesity Society) and expert consensus documents suggest the following approach: Hold GLP-1RA in the acute perioperative period. For daily-dosed ...
When do you send for genetic testing (e.g., SPINK1, PRSS1, CFTR) in a patient with recurrent or chronic pancreatitis without an obvious etiology and how does it impact your management?
I offer and discuss getting genetic testing in patients with idiopathic recurrent acute pancreatitis or chronic pancreatitis, more frequently in younger patients. Impact of testing can help identify undiagnosed CFTR patients, for whom further CF evaluation and management including options to try new...