Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
Do you routinely check Infliximab levels on day 3 with patients admitted with acute severe ulcerative colitis?
The question implies that the patient has received the first induction dose of IFX just three days earlier. If that is the case, day 3 seems too soon to check a level. Normally, we might check a trough level just before the second dose in two weeks. If the level is low, we would increase the second ...
How do you approach the use of fidaxomicin versus vancomycin for initial Clostridioides difficile infection in immunocompromised patients, considering the lower recurrence rates but higher cost of fidaxomicin?
Whether immunocompromised or not, fidaxomicin has been demonstrated to be superior to vancomycin – not in resolution of the acute infection but in reducing the risk or recurrence by approximately one-half. In one study of hospitalized patients published in 2015, it was reported that, when taking int...
What is your approach to secondary prophylaxis and post-discharge planning after an acute esophageal variceal bleed in a patient with ongoing alcohol use disorder and major social barriers (uninsured, homeless)?
Obviously, these questions are moot in the setting of an acute variceal bleeding when a life-saving TIPS becomes necessary; we then deal with these issues afterwards. We frankly go as far as we can with medical/endoscopic therapy before considering TIPS as an option for repeated bleeding episodes, w...
Is there evidence that certain PPIs provide superior clinical efficacy compared to others in real-world practice?
While there are some differences between PPIs in terms of metabolism, bioavailability, and duration of acid suppression, generally speaking, in clinical practice, the efficacy of different PPIs is comparable. With that said, some differences include dexlansoprazole's dual-release nature which genera...
What is your preferred analgesic in patients with small bowel obstruction or ileus?
I typically use IV Tylenol ATC if fully obstructed, and IV Toradol if no other contraindications to NSAIDs (and they often are quite prerenal or losing a lot of fluid from an NG tube, so I often don't feel comfortable with more than a couple doses, and if I think they are going to the OR, I do not u...
How do you approach HCC screening in patients with advanced fibrosis e.g., F3 on FibroScan?
We should first understand the underlying principles that defined the various cut-offs that resulted in this recommendation (eg, cost-effectiveness threshold for HCC screening, cut-offs for advanced fibrosis) and then go from there. Among patients with cirrhosis, the cost-effectiveness threshold wa...
How do you decide between anticoagulation and observation for an incidentally detected subsegmental pulmonary embolism in elderly patients with a history of gastrointestinal bleeding?
We face this conundrum not infrequently because subsegmental emboli are subject to high inter-reader variability, and the accuracy of the finding in isolation is suspect (Batayneh et al., Blood 2023). I once mentioned this to a radiologist who reads CTAs and was told, tactfully, that I was full of i...
Do you avoid peritoneal dialysis in cirrhotic patients with ascites?
There are two major concerns regarding the performance of PD in patients with ascites: the potential for fluid leakage at the site of the newly placed catheter and the perceived increased potential for peritonitis. In my experience, neither of these is a compelling reason to shy away from PD in a pa...
What techniques do you find most effective for visualization of rectal disease with intestinal ultrasound?
I am not sure that this is the correct use of "intestinal ultrasound". There is the transabdominal ultrasound technique that is taught to gastroenterologists who can use it at point of care for their UC and CD patients to assess the small bowel and the colon. If you want to specifically look at the ...
In light of recent measles outbreaks in the US, would you recommend an MMR booster for immunocompetent patients born before 1957?
I would not recommend a measles vaccine for a person born before 1957. This year has been chosen because people before born before 1957 have a very very high likelihood of having had measles because virtually all children got this highly contagious disease. On the other hand, there is no harm to get...