Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
In what cases do you use baclofen for alcohol use disorder?
As Dr. @Dr. First Last mentioned, it's generally not a first-line choice (at least in the US). It is much more popular in Europe, but efficacy usually comes at notably higher doses. In one case series from 144 patients treated with baclofen in a French clinic, the mean maximum dose was 211 mg daily ...
With the growth of non-alcoholic beverages (e.g., NA beer, liquor, etc), how do you approach a patient's consumption of these products in the setting of alcohol related liver disease?
This is definitely a challenging conundrum to deal with. Historically, even the NA beverages would have 0.5% alcohol, so they weren't truly NA. With time, that has seemingly changed. Regardless, my approach is the same. I strongly advise against the idea that NA beverages are allowed. Mostly because...
How do you approach the workup for a patient with imaging showing features suggestive of cirrhosis?
It is important to clarify what features of the imaging are resulting in this diagnostic impression. Liver nodularity without other findings of cirrhosis is non-specific and does not make a diagnosis of cirrhosis. An incidental finding of a nodular liver with normal liver enzymes and normal platelet...
In patients with hepatitis B and co-infection with hepatitis D, given their increased risk of development of HCC, how do you approach screening for this?
Screening frequency is based on tumor-doubling size and not risk of HCC. Every 6 months, imaging is recommended + AFP. HDV patients should be screened if advanced fibrosis (F3-4) is present or VCTE > 9 kPA.
How do you counsel patients on the risks vs benefits of naltrexone for alcohol use disorder with persistently elevated liver enzymes?
Before answering this question, it is first important to point out that obtaining baseline liver function tests (LFTs) is not necessary before starting a patient on any formulation of naltrexone (oral or long-acting injectable XR). However, it is essential to consider if the patient has an underly...
When would you consider quantification of hepatitis B surface antigen as part of the treatment decision making process?
The other issue with quantitative sAg is eligibility for clinical trials and potentially to be able to use the new GSK drug Bepe in the near future. Patients with s levels below 1,000 are much more likely to clear their surface antigen than those with levels above 1,000.
How do you pragmatically approach a conversation about "liver detox"/"liver cleansers" when patients bring up this topic?
It's important to keep an open mind with the use of these products, as often people will want to take them despite what you might say. Having some experience with the use of these products (or at least their ingredients) will give the patient a comfort level with freely discussing their use with you...
How do you approach the optimization and risk stratification of a cirrhotic patient who is undergoing extra-hepatic abdominal (or other) surgery?
I primarily use the VOCALPenn scoring system to provide risk estimates and then provide guidance regarding volume resuscitation, anesthetic/sedation limits, and pain medication recommendations. Ultimately, our job is not to "clear" someone but to provide as accurate a risk assessment to the surgical...
What clinical scenario do you consider screening for hepatitis delta?
I test every new patient with at least a Delta antibody. If patients have elevated ALT but low level HBV DNA levels, I will get a HDV RNA as my first test.
Do you recommend starting naltrexone at discharge for alcohol use disorder in patients with decompensated cirrhosis secondary to alcohol use?
Although naltrexone is generally safe to use in patients with cirrhosis, I would be cautious to use it in patients with decompensated cirrhosis, since it is mainly metabolized in the liver. I usually use acamprosate in patients with decompensated cirrhosis, with high bilirubin, as long as renal func...