Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
How long do you typically treat patients with phentermine for weight loss and what clinical markers do you follow?
Phentermine has been available since 1959 and remains an affordable and effective medication option added to a full lifestyle-based weight management plan. In people who are generally healthy and without contraindications to the medication, I have had patients used in at least intermittently for sev...
In a patient with low (or normal) BMI but findings of steatosis on imaging, no cardiometabolic comorbidities, and very elevated CAP scores, what are your next diagnostic and therapeutic steps to identify the cause of their steatosis and subsequent management?
In addition to knowing the level of steatosis, liver stiffness values would be of most interest. Alcohol use should stop if there is any level of fibrosis. Lifestyle modifications (dietary/exercise) should be part of recommendations, but with a goal of around 5 % weight loss. If they have F2-3 fibro...
How would you manage a patient with well-controlled HIV on Biktarvy, who is interested in switching to injectable HAART but also has a history of a prior Hepatitis B Infection?
HBV is a common co-infection in people with HIV (PWH), due to shared transmission routes. Two large meta-analyses of studies published found a global a pooled prevalence of HBV infection among PWH to be between 7.6 and 8.4%, with a higher prevalence in less developed countries (10.4%) compared to mo...
What is your strategy to manage the complication of long-term immunosuppression in liver transplant recipients, specifically renal dysfunction and onset of cardiometabolic comorbidities?
Educating patients early on after their transplant is important as to the medical complications associated with CNI use. With regard to renal dysfunction, trying to minimize CNI use as judiciously and as timely as possible is paramount. Switching to an mTOR inhibitor appears best to do early on afte...
How do you use IVC caliber and collapsibility to guide decisions about diuresis?
I use IVC caliber in conjunction with my lung exam to assist with the assessment of right and left atrial pressures respectively. The IVC assessment has many caveats in different patient populations, and evaluation with POCUS can be done in two planes to better understand IVC shape.Caveats - IVC siz...
Which patients, if any, do you revert back to ultrasound screening for HCC after prior diagnosis/definitive treatment of HCC?
I don't revert back to U/S for these patients ever. It's not dissimilar from colorectal cancer screening - once you have colon cancer, it's not appropriate to use iFOBT or stool DNA screening anymore - it's lifelong colonoscopy screening. Likewise, for HCC, I continue to use AFP plus cross-sectional...
How would you approach the evaluation of a patient with decompensated cirrhosis, suspect to be due to alcohol, who is not a liver transplant candidate with iron studies showing elevated saturation and ferritin over 1000?
The finding of elevated iron saturation (I suspect means above 55%) and high ferritin raises the diagnosis of true iron overload. Certainly, a Ferritin level above 1000, when the patient is not actively drinking, is consistent with cirrhosis. So, I would start phlebotomies if the Hgb >11-12 g/dL all...
What is your strategy in the management of patients with autoimmune hepatitis who failed azathioprine therapy and what parameters do you monitor with what frequency?
Great question. Around 10% of autoimmune hepatitis cases don't respond to azathioprine (AZA) and 15% may have an incomplete response to AZA. These patients require second-line therapy. Before initiating second-line therapy, it's important to exclude non-adherence. Mycophenolate Mofetil (MMF) is the ...
How do you decide when to use acid-suppressive medications for GI prophylaxis when patients are on prolonged corticosteroid therapy?
Consideration of risk factors is important. Routinely, someone without these risk factors, and if getting a short burst of steroids, the GI prophylaxis is not given. PPIs carry certain risks, including increased risk of C. Diff infection or even pneumonia. So, they should be avoided if not indicated...
In what clinical scenario would you consider liver transplant evaluation for a patient with sickle cell hepatopathy?
I would do a concurrent stem cell transplant - in an effort to cure the underlying problem of sickle cell disease. Ideally, the same donor to prevent graft rejection.