Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
How are you treating MSI-H CRC in a liver transplant recipient on tacrolimus & sirolimus?
This is an important question; however, our experience in the metastatic colorectal cancer (mCRC) setting remains very limited. This patient underwent liver transplantation three years ago and has since developed dMMR/MSI-H metastatic colorectal cancer. The patient is currently receiving tacrolimus ...
How do you decide between anticoagulation or portal vein recanalization in a patient with portal vein thrombosis?
It depends on cirrhotic vs non-cirrhotic. For cirrhotic, best to reference the AASLD 2020 guidance here - Northup et al., PMID 33219529.For non-cirrhotic: important to determine the etiology as well as evaluate for a hypercoagulable state, including checking for JAK2 and CALR.If acute and non-occlus...
How does VExUS evaluation differ in a patient with a transjugular intrahepatic portosystemic shunt (TIPS)?
This is a very interesting question, and I don't think I have ever tried to look at VExUS in a patient with a TIPS before! Although, based on what I understand about this study, I would be cautious about relying on the original VExUS algorithm that incorporates hepatic vein, portal vein, and intrare...
In what clinical scenario would you consider the use of budesonide over prednisone as part of the pharmacologic management of autoimmune hepatitis?
Primarily in patients where the side effects of prednisone will or are too difficult to tolerate (diabetics, weight gain, metabolic syndrome, psychiatric disease, etc). I like to try prednisone first because of its ability to elucidate a biochemical response, fairly rapidly, so we know what we are d...
In suspected antibiotic-associated cholestatic DILI with jaundice and no obstructing lesion on MRCP, what specific clinical or laboratory trajectory triggers you to proceed to early liver biopsy to evaluate for evolving vanishing bile duct syndrome rather than continued close outpatient monitoring?
This is an important question because early awareness and a confirmed diagnosis will result in a better outcome. 1- Needs a clear history and exclusion of other potential etiologies. 2- Need to know whether the patient has underlying liver disease, i.e., metabolic dysfunction-associated steatotic li...
In pregnant liver transplant recipients, which transplant-specific modifiable targets do you prioritize to reduce prematurity and fetal growth restriction?
There is no data or guidance on how to reduce prematurity or fetal growth restriction in transplant recipients.However, regarding this patient population, the AASLD Practice Guidance on Reproductive Health summarizes the key points nicely of what's recommended in liver transplant recipients planning...
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 treat diffuse large B cell lymphoma (DLBCL) in a patient with cirrhosis complicated by thrombocytopenia?
Thank you for the question. This is a very challenging case. There are different factors to consider, such as age, PS, stage, and actual liver function. Liver function may have been affected by lymphoma.Most likely, the patient will require dose reductions of standard R-CHOP (such as mini R-CHOP). A...
What early response criteria and timeframe do you use to declare corticosteroid non-response and move to expedited transplant listing in patient with acute severe AIH without encephalopathy?
I would administer the corticosteroid as an IV to remove the possibility of absorption issues. However, I would wait for a total of 5-7 days before moving on to expedited transplant listing, provided there is no worsening of the liver failure in the interim.
Do you recommend restarting a GLP-1RA after bariatric surgery if the patient tolerated it before the surgery?
While there are no clear recommendations on whether/when to resume GLP-1 RA after bariatric surgery, current 2025 guideline statements (ASMBS, ADA, AACE, Obesity Society) and expert consensus documents suggest the following approach: Hold GLP-1RA in the acute perioperative period. For daily-dosed ...