Internal Medicine&nbsp;&nbsp;&nbsp;

How would you manage a patient with Crohn's disease on a biologic and presents with non-bloody diarrhea, normal-appearing mucosa on sigmoidoscopy but severe colitis on biopsy with a positive CMV stain?

Would you send a CMV DNA PCR in blood, and if you elect to treat with anti-CMV medication, how long would you treat and what parameters would you use,...

How would you manage an elderly patient with type 3 achalasia who previously underwent POEM and has recurrent dysphagia, high Eckardt score, and dilated esophagus concerning for blown-out myotomy on esophagram?

Would you recommend repeat POEM, Heller myotomy, or pneumatic dilation?

How do you practically approach a tailored elimination diet in young patients with numerous food impactions and esophageal strictures who are intermittently compliant with PPI or topical steroids?

How do you practically approach a tailored elimination diet in young patients with numerous food impactions and esophageal strictures who are intermit...

What diet do you recommend for patients with inflammatory bowel disease?

What is your approach to choosing a particular advanced therapy based on patient or disease factors when initiating treatment for moderate-severe IBD?

How do you counsel patients who experience diarrhea from mycophenolate mofetil (Cellcept)?

Do you generally recommend anti-diarrheals, dietary modifications, or consider this an unacceptable side effect and move to other therapies?

How do you approach a patient on anti-TNF with positive Quantiferon (previously negative) with negative chest x-ray and no symptoms?

7 Answers available

Is there a role for use of dupilumab for hypereosinophilic GI disorders distal to the esophagus?

How do you approach managing nausea and GI side effects when initiating methotrexate?

How do you counsel patients on the use of compounded weight loss medications?

How would you approach management of a patient with a medium-to-large vessel vasculitis who developed perforation of the stomach and colon on steroids and cyclophosphamide?

Vasculitis involving aorta, subclavian, common carotid, SMA, IMA, renal artery, and celiac artery.

How do you approach managing depression symptoms in patients who have had repeated high risk of bleeding?

When do you determine SSRI therapy is unsafe to pursue in such situations?

Do you avoid terlipressin for patients with hepatorenal syndrome who have a serum sodium level less than 125 mEq/L?

Do you feel comfortable using Jak inhibitors in patients with a strong family history of CAD, but no other risk factors?

How do you counsel patients in this scenario?

Is there a role for the use of transient elastography (FibroScan) to monitor liver fibrosis in patients on long term methotrexate?

Is there a role for nitazoxanide for treatment of norovirus gastroenteritis in immunocompromised patients?

Is there a role for anti-IL5 therapy in the treatment of EoE?

Under what circumstances would you recommend early fecal microbiota transplantation over antibiotic treatment or bezlotoxumab in a patient with recurrent C. difficile infection?

What is your approach to duration of fidaxomicin in a patient receiving treatment for first C difficile infection while also receiving concurrent antibiotics for an infection?

Do you extend the course of fidaxomicin past initial 10 days to at least 3-7 days after completion of antibiotics?

When would you phlebotomize patients with secondary hemochromatosis, such as due to NAFLD/cirrhosis?

HFE gene mutations in C282Y and H63D are negative.

What is your approach to treatment of patients with fulminant C difficile infection who required ileostomy creation or colectomy?

Is there a role for oral vancomycin in these patients, or is oral vancomycin redundant if other routes of administration are being used (i.e intracolo...

Is there a risk of hepatitis C activation with rituximab in a patient who has a history of HCV treated with antivirals and who is in sustained viral response?

What non-variceal EGD findings, if any, deter you from using atezo/bev in patients with advanced HCC?

Would portal hypertensive gastropathy or colopathy sway you away from using it?

How long do you treat an isolated bacterial liver abscess which has either undergone percutaneous drainage or for which an indwelling drain is placed?

How do you monitor patients with incidentally found high titer anti-smooth muscle antibodies without stigmata of liver disease?

How long do you continue antibiotics after cholecystostomy tube placement for acute cholecystitis?

Since the COVID-19 pandemic, increasingly we see management of acute cholecystitis with cholecystostomy tubes as opposed to surgery, even amongst pati...

What approaches can we take to initiate therapy and improve survival rates in patients with HLH?

How would you manage a patient with highly active ankylosing spondylitis, iritis and Crohn’s, controlled with weekly adalimumab with co-morbid IgG4RD and intolerance of azathioprine due to elevated LFTs?

IgG4 manifestations include autoimmune pancreatitis and periaortic soft tissue mass.

How would you manage a solitary unresectable liver metastasis?

From NCCN (Rectal MS-33): SBRT is a reasonable option for patients who cannot be resected or ablated. What is the role of SBRT versus microwave ablat...

What is your approach to working up diarrhea in an immunocompromised patient?

Do you have concerns with the use of oral contraceptives in patients on JAK inhibitors given the black box warning for thromboembolic events?

How has this impacted your counseling and management?

How would you manage autoimmune pancreatitis in a patient after Whipple's procedure?

How do you approach an obese patient on long-term methotrexate with normal liver tests in terms of workup for underlying fatty liver?

Would you start with a baseline ultrasound and then pursue further workup such as fibroscan if fatty liver is present, or other?

How do you approach GI prophylaxis (e.g., PPIs, H2 blockers) in patients on long-term NSAIDs?

Do you consider anti-viral prophylaxis in patients taking JAK inhibitors who have recurrent uncomplicated Zoster infection, but would prefer not changing therapy?

Does hepatitis B vaccination reduce the risk of HBV reactivation associated with immunosuppressive therapy?

For example, in patients who are HbSAg negative, anti-HBc positive and HbSAb negative, does vaccination reduce reactivation risk?

In a patient with recurrent fibrolamellar HCC a year after upfront resection (previously refused adjuvant therapy) with a solitary abdominal mass, would you offer neoadjuvant therapy to assess response?

Or offer resection followed by adjuvant therapy?

How would you approach additional workup and management of a patient with active Crohn’s disease, who has multiple lung and brain nodules, with lung pathology demonstrating necrotizing granulomatous inflammation and brain biopsy with granulomatous inflammation and medium-large vessel vasculitis?

The patient is on mesalamine for Crohn’s and CellCept and HCQ for skin manifestations (currently on hold during workup). The infectious workup i...

How long do you anticoagulate for cirrhosis patients who have portal vein thrombosis extending to the mesenteric veins?

Do you have a preference between Quantiferon Gold and T-spot TB for screening in patients starting immunosuppressive agents?

Do you stop TNF inhibitors during the third trimester of pregnancy?

Would you treat an unresectable MSI-H colon cancer patient with persistent hepatitis C with immunotherapy?

How do you manage patients with suspected cholangiocarcinoma that presents with biliary obstruction but has repeated negative brushings/biopsies?

Is liquid biopsy helpful? Would you treat if this shows somatic mutation?

How do you employ focal therapies in localized hepatocellular carcinoma?

Will the results of the recently published randomized comparison of proton beam therapy (PBT) vs. transarterial chemoembolization (TACE) change the wa...

Which biologics are you comfortable combining with vedolizumab for spondyloarthritis or psoriatic arthritis patients in the setting of well-controlled inflammatory bowel disease?

What initial workup do you perform when there is a concern for porphyria?

What is your approach to continuing or altering therapy when inheriting a patient with combined biologic immunosuppression that is in excess of guidelines?

How do you approach de-escalation or justify therapy maintenance? Do you have tiers of medications that you attempt to de-escalate first? In one parti...

What is your approach to management of elevated liver enzymes in patients who recently started treatment with tocilizumab?

What is your approach to pharmacologic treatment options in a patient with both SLE and Crohn's disease?

A female in her 50s with iatrogenic Cushing's Syndrome presenting for management of SLE with low disease activity (but not remission) in the setting o...

How do you approach relapsed hepatocellular malignant neoplasm NOS after transplant in pediatric or AYA patients?

Would you be comfortable using a JAK inhibitor in a patient with baseline thrombocytosis?

Would the etiology of the thrombocytosis play a role in your decision-making?

Should all patients diagnosed with B12 deficiency get a baseline EGD?

Should they be placed on routine EGD surveillance and if yes at what intervals?

How do you counsel patients about the malignancy risk associated with azathioprine?

In patients chronically treated for Wilson's disease with trientine hydrochloride (Syprine®), would you expect development of neurologic symptoms?

Do you discontinue or adjust azathioprine when a patient develops elevated MCV after starting it?

When it seems fairly certain that this is a drug effect is it something that can just be monitored or requires a change in approach?

How do you treat celiac disease associated inflammatory arthritis refractory to gluten free diet?

How would you treat a patient with recurrent metastatic HCC 6 years after liver transplant for HCC?

How do you approach the continued use of TNF inhibitors in a patient with inflammatory arthritis who develops a positive dsDNA without clinical evidence of drug-induced lupus?

How do you select systemic therapy for advanced HCC patients with portal vein thrombosis?

What is your treatment approach for a patient with metastatic hepatocellular carcinoma with Child's Pugh B cirrhosis?

How do you sequence systemic treatment options for in patients with Child's Pugh B (or greater) in context of IMbrave150 and HIMALAYA? When do you in...

4 Answers available

What is your treatment algorithm for management of retroperitoneal fibrosis that does not respond to high-dose glucocorticoids?

When would you consider rituximab as induction therapy in IgG4-related disease?

4 Answers available

Would you intensify therapy in IgG4 related disease based solely on a persistently significantly elevated IgG4 level when all disease manifestations and inflammatory markers have normalized?

Do you recommend probiotics to patients receiving pelvic radiotherapy?

Is there a specific brand or formulation you prefer? The literature supporting the use of probiotics does not standardize the type or dose of probiot...

How would you approach a patient with imaging and labs suggestive of potentially resectable cholangiocarcinoma when several core biopsies reveal bridging fibrosis with no malignant cells?

In patients with HCC and asymptomatic but endoscopically visible varices, how long do you wait to start bevacizumab after banding?

Is there a role for regular hepatitis and TB screening in patients on chronic immunosuppressive therapy in the absence of new risk factors or exposures?

What would be your next line of treatment for disease control in a pediatric patient with metastatic hepatocellular carcinoma in partial response after multiple therapies?

The patient already received PLADO+sorafenib, Y90, and Atezolizumab/Bevacizumab complicated by recurrent episodes of bleeding from esophageal varices....

How would you approach new-onset large vessel vasculitis in a young patient with Crohn's disease?

How would you approach asymptomatic hepatic sarcoid?

Multiple lesions on PET

Is prophylactic anticoagulation indicated in patients with frequent ulcerative colitis flares?

If so, what agent(s) do you prefer?

How would you treat a poorly controlled seronegative RA patient who is steroid dependent and is on azathioprine for autoimmune hepatitis?

Is there a role for liver transplantation in an initially unresectable HCC with a complete response after bevacizumab-atezolizumab?

How do you approach treatment of metastatic hepatocellular carcinoma in an adolescent?

Would you offer liver transplant in the setting of metastatic disease?

What is the role of liver transplant in NET?

With what agents can you replace PPIs if they cause thrombocytopenia?

Should platelet transfusions be considered for anti-platelet agent reversal in patients with major bleeding?

Would you recommend stent placement upfront in a patient with cervical esophageal cancer and a TE fistula?

How do you approach screening for inflammatory bowel disease prior to starting IL-17 inhibitors?

How do you approach a patient with IgG4-related disease who has failed rituximab and mycophenolate and continues to rely on high-dose steroids?

The case I am considering involves a patient with biopsy-proven fibrosing dacryoadenitis.

Do you recommend checking anti-drug antibodies for patients on TNF inhibitors?

If so, how would positive levels guide your management?

Do you routinely start anticoagulation for a patient with newly diagnosed hepatocellular carcinoma presenting with a portal venous thrombosis?

What is your preferred second line therapy for an HCC patient who progressed after first line checkpoint inhibitor monotherapy?

Would you try atezolizumab/bevacizumab or switch to a TKI?

For palliation of gastric bleeding due to malignancy, is a G-tube a contraindication for RT?

Would you reduce dose, e.g. from 30 Gy in 10 fractions to 20 Gy in 5 fractions, or hyperfractionate, e.g. 1.5 Gy bid to 20-30 Gy?

Would you use an IL-17 inhibitor for a psoriatic arthritis patient with inactive inflammatory bowel disease?

Is anticoagulation a relative contraindication to atezolizumab/bevacizumab for advanced HCC?

For example in a patient with a history of PE?

For patients with HCC receiving atezo/bev, would you advise any other clinical investigations scheduled during treatment other than basic lab monitoring?

i.e. EGD surveillance for varices?

Are there any biomarkers that might indicate who might be responders to atezolizumab/bevacizumab for HCC?

ex. VEGFR2 expression, inflammatory signature, PDL1, etc.

How do you manage patients on atezolizumab/bevacizumab with advanced HCC who develop arterial thrombosis?

Do you continue atezolizumab alone? Would you avoid anticoagulation?

6 Answers available

For patients with HCC that have stable disease on immunotherapy alone, would you consider adding bevacizumab at the time of disease progression and continue immunotherapy?

How do you decide between systemic vs. arterially directed therapies in the first line setting for unresectable HCC?

In light of the SIRveNIB trial results and now IMbrave150, what is the role of intra-arterial therapy now?

Would you hold all immunosuppressive medications for the first month of LTBI treatment, or just biologics?

Would you use upfront atezo/bev in a patient with HCC and untreated hepatitis?

Do you refer all of your patients for EGD prior to initiation of atezolizumab/bevacizumab for advanced HCC?

Do you screen even asymptomatic patients?

4 Answers available

Do you utilize EUS to determine the nodal radiation fields in esophageal adenocarcinoma?

In a patient with a large primary and a negative PET/CT for nodal disease, would you push for EUS for radiation planning? Or would this be an unnecess...

Do you avoid any specific biologic therapies in HIV positive patients?

How do you assess transaminitis in a patient with sarcoidosis with known liver involvement being treated with methotrexate?

How do you manage patients who are Hepatitis B core antibody positive/surface antigen negative and starting a biologic DMARD (other than rituximab)?

How do you counsel patients who ask if there are any dietary modifications they can make to help control their autoimmune disease?

This question is part of a collaboration with RheumMadness and is specifically in reference to: ADIRA Diet

Is it okay to use COX-2 selective NSAIDs in patients with IBD-associated arthritis when the IBD is in remission?

Would you re-challenge patients who have had a TNF-associated paradoxical adverse event (such as inflammatory bowel disease) with a different TNF inhibitor?

What is your treatment algorithm for solitary hepatocellular carcinoma, 3-5 cm, non-operative candidate but Child-Turcotte Pugh A/B?

Do you recommend TACE, RFA, radioembolization, systemic therapy or SBRT? What if the size is >5 cm?

Are you routinely using thrombopoietin agonists in patients with hep C and HCC?

If so, for what platelet count threshold and do you have a preference as to which agent?

How do you sequence antiviral therapy and cancer-directed therapy in a newly diagnosed patient with hepatocellular carcinoma and incidentally found hepatitis C?

Is there a "best" way to approach treatment of the viral infection i.e concurrently with therapy, prior to therapy, delayed or post therapy? Does this...

What is your general approach to treating bleeding gastric masses with palliative RT?

Do you have any preferred dose fractionation schedules? What kind of margins do you use?

How do you manage venous thromboembolic events or bleeding events in RCC or HCC patients on anti-angiogenic TKIs?

Arterial events have clear instructions to permanently discontinue on the FDA label. Especially in HCC without many other treatment options, giv...

Are you categorically using lenvatinib over sorafenib for unresectable HCC in the absence of contraindications?

Is it necessary to hold immunotherapy during a 4-6wk steroid taper after resolution of immunotherapy related toxicity?

Would you ever considering re-starting immunotherapy before completing the taper? According to the new guildelines on managing immunotherapy related ...

Would you recommend sorafenib as an adjunct to liver targeted therapy in patients with hepatocellular carcinoma who are awaiting liver transplant?

Could a non-cirrhotic patient with a single HCC lesion measuring >5cm who is ineligible for liver transplant by Milan size criteria alone become a candidate if the tumor shrinks after TACE?

Has pelvic MRI replaced EUS as the standard of care for rectal cancer staging?

Are there any indications to choose one over the other?