Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
For pediatric patients with iron overload (high ferritin and transferrin saturation), do you perform HFE screening first, or proceed to non-HFE gene sequencing upfront to evaluate for HJV mutation as well?
Because there is no recommended "screening" scenario for iron overload in pediatrics (especially with no family history), the question for me revolves around "why did the patient get tested in the first place?" If it were a routine screen for iron deficiency, which affects millions of children at an...
How do you evaluate and manage acute alcohol withdrawal when symptom-driven protocols are confounded/unreliable?
Often, if someone has an underlying condition that may artifactually elevate their symptom monitor scores (such as essential tremor in CIWA-Ar or tachycardia from cancer or sepsis in mMINDS), I will do any of the following: Increase the threshold for the symptom-triggered med by a few points (if th...
What is your endoscopic approach to the management of refractory GAVE in persistently anemic patients?
Approaches that I use: Reduce PPI use if able. There is some data that PPIs may make GAVE/DAVE and PHG worse and on occasion, stopping PPI has improved the overall appearance. Some positive data regarding the use of beta blockers for GAVE, although not that great. Depending on the definition of ref...
How do you approach the use of the quantification of HBsAg titers in chronic hepatitis B infection who are eAg negative with viral suppression on treatment?
The use of hepatitis B quantitative surface antigen has been increasing in recent years. There b are several uses for it. A very low level indicates a high likelihood of S antigen clearance, so a patient, who might want to stop taking their nucs would be reassured if their level was less than 100. O...
If a patient has persistent ascites requiring diuretics after TIPS, at what point do you consider re-evaluation of TIPS?
Some may still require some diuretics, particularly if lower extremity edema is an issue post-TIPS. Otherwise, if paracentesis is needed ~6 weeks after TIPS and the patient is free of HE, then consider IR dilating the TIPS further. When TIPS is for ascites, IR should really start with a small calibe...
How do you manage anticoagulation/antiplatelet therapies with strong indications for uninterrupted therapy in setting of urgent procedures?
If anticoagulation is absolutely contraindicated because of the bleeding risk of the procedure, then "bridging" will usually make the most sense, most of the time, with low molecular weight heparin such as enoxaparin. If dual antiplatelet agents are contraindicated, particularly in the first month a...
Do you use lactulose in acute liver failure, particularly in patients on continuous renal replacement therapy (CRRT) for ammonia or toxin clearance?
Generally lactulose should be avoided in the situation given limited benefit as well a tendency for ileus in ALF and potential for lactulose to cause bowel distention.
Is there benefit to aggressively treating hemochromatosis in a patient who has already progressed to cirrhosis at the time of diagnosis?
The short answer is yes, there is a benefit to treating iron overload in a patient with hereditary hemochromatosis (HH) with cirrhosis. HH involves at least five mutations, most commonly in the HFE gene (common variants include C282Y and H63D), leading to hyperabsorption of iron and progressive accu...
How would you approach a referral for concern for hemochromatosis with ferritin elevation but otherwise normal iron studies?
Interesting questions, but lack of specifics about the degree of elevation and what constitutes normal iron studies makes it difficult to directly answer this question. However, there are well-recognized causes of elevated ferritin due to non-iron overloaded conditions, including increased apoferrit...
How would you approach the management of a patient with elevated iron saturation (60%) and ferritin (500s) with negative genetic testing for hemochromatosis?
I would approach this clinical scenario in the following manner: Always starting with good medical and family history first. Is there any history compatible with secondary hemochromatosis (i.e., history of blood or multiple iron transfusions)? Could the patient be tested for other non-282Y genetic ...