Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
How do you decide when to initiate or restart diuretics in a cirrhotic patient with ascites if they are receiving a therapeutic paracentesis?
This question has two parts, one with a straightforward answer, the other with a much more nuanced answer, if I understand it correctly. Any patient receiving a therapeutic paracentesis should start/restart diuretics afterwards. Per the 2021 AASLD guidelines, one of the statements reads “LVP is the ...
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)...
How do you decide whether to use pharmacologic VTE prophylaxis in hospitalized patients with decompensated cirrhosis?
For all patients, I begin by using a standard risk prediction tool to determine if the patient is appropriate for pharmacologic VTE prophylaxis. At our institution, the Padua risk prediction tool is embedded in our electronic health record/admission set. Clinical guidelines- including those from the...
When ALT is persistently normal and HBV DNA is high but noninvasive markers suggest more advanced disease, how do you triage between biopsy, immediate antiviral therapy, or close observation—and which discordance patterns most strongly suggest “silent” progression in your experience?
ALT means absolutely nothing to me. High DNA is very contagious and much more likely to cause fibrosis and liver cancer, let alone the more replication, the more integration into the hepatocyte genome, which is the main cause of liver cancer. Liver biopsy has no role here either; fibrosis is not the...
How do you decide between urgent early liver transplant listing versus a time-limited “watchful waiting” strategy in critically ill severe alcohol-associated hepatitis with some signs of potential hepatic recovery?
Often, these decisions are very difficult to make and have to be individualized per patient. Of course, if a patient is responding biochemically to a course of corticosteroids, transplantation will be deferred (non-response or contraindication to steroids is usually a component of the evaluation of ...
Would you recommend phlebotomy for a patient with previously treated ALL and HBV reactivation both now in remission but with elevated liver enzymes and ferritin, and liver biopsy with widespread peri-canalicular moderate iron deposition and perisinusoidal fibrosis with focal periportal fibrosis?
The case presented is not unusual. Patients do not always recall the number of transfusions received. I favor secondary hemochromatosis. If her HGB is above 11-12 g/dL, she could tolerate phlebotomies. I would be gentle with the schedule of phlebotomies, maybe a couple in 1-2 months, and follow her ...
Do you obtain liver biopsy to confirm the diagnosis of cirrhosis if cirrhotic liver morphology is noted on imaging?
This question touches upon two interesting trends: 1) There is an increasing trend in Radiology to report "cirrhotic liver morphology" in the "Impressions" section. When you then review the Body of the report, often these cases are noted to only have a heterogeneous appearing liver with surface nodu...
What is your approach to the management of post-TIPS hepatic encephalopathy?
In general, this will depend on if HE is provoked or unprovoked. Provoking factors such as infection, dehydration, medications (sedatives) or GI bleeding are reversible and often do not require aggressive HE treatment when the underlying trigger is removed. It may be reasonable to consider lactulose...
In AIH/PBC overlap with both hepatitis and cholestasis, how do you determine whether incomplete biochemical response at 6–12 months reflects undertreated AIH versus inadequately controlled cholestasis?
Overlap can be very challenging to treat. In this situation, it is reasonable to perform a repeat liver biopsy. If autoimmune hepatitis remains active, it would increase the IS.
How do you consider the clinical relevance of elevated serum B12 levels as a marker of underlying hepatic disease?
Elevated B12 levels have shown significant relevance and significance to many underlying conditions, particularly a high correlation with underlying liver disease. About 1 in 5 to 1 in 4 B12 levels >1000 pg/ml had a significant correlation. It is a prognosticator, in my opinion, and the literature s...