Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
Do you refer all of your patients for EGD prior to initiation of atezolizumab/bevacizumab for advanced HCC?
Per the trial, this was required within 6 months of starting the study. However, in practice, I don't know that this strict rule would be necessary. For example, what if an EGD was done 10 months ago without varices? I don't think I would feel strongly about this. Similarly, if we could get one shor...
How do you approach the management of older adult patients with coronary artery disease on aspirin who have developed intermittent diverticular bleeds?
I agree with Dr. @Dr. First Last. For patients over age 70 with chronic stable CAD, the absolute benefit of low-dose aspirin for prevention of MACE or stroke is 1-2% per year, which yields a number needed to treat (NNT) of 50-100 patients to prevent 1 event per year. Following Dr. Bayer's comments, ...
How would you manage an asymptomatic patient after VCE showing small bowel Crohn's who passes the patency capsule but has retained the video capsule in the distal ileum with minimal surrounding inflammation?
A capsule can take up to 10 days to pass in a normal situation. If you have radiographic evidence of a retained capsule and the patient is on prednisone, it might take another 2 weeks or so to get the inflammation down. Remember that the capsule should continue to get crushed and really should pass ...
What is your preferred approach in treating recurrent bleeding from GAVE?
If repeated APC has not helped, I ask our advanced endoscopists to perform RFA. If it is a nodular GAVE, then banding is another option.
Would you use upfront atezo/bev in a patient with HCC and untreated hepatitis?
Yes. I would not have concerns. For HBV, I would start treatment before or simultaneously. Studies have varied by protocol about the HBV viral load being under 500 or 100 but it is not clear this matters. There have not been flairs reported. In regards to HCV, again, not an issue for me.
How do you decide between systemic vs. arterially directed therapies in the first line setting for unresectable HCC?
In IMbrave150, 63% of patients treated with atezolizumab/bevacizumab had extrahepatic spread of disease, and my recommendation for patients with extrahepatic involvement is for first line systemic therapy. For patients with unresectable disease without extrahepatic spread, we take a multi-disciplina...
Do you recommend checking anti-drug antibodies for patients on TNF inhibitors?
This is a very good question with direct clinical practice implications. I do not check or follow anti-drug antibodies when using TNF inhibitors for the treatment of rheumatoid arthritis or psoriatic arthritis. There are reports that suggest, on a group level, that these antibodies, if present, impa...
What is your approach to peri-operative risk stratification and optimization in patients with cirrhosis?
The VOCAL-Penn score is one piece of information that I use for risk stratification in patients with cirrhosis. I usually treat symptomatic decompensated cirrhosis first (hepatic encephalopathy, ascites, hepatic hydrothorax, hepatorenal syndrome, variceal bleeding), because the risk scores usually c...
In patients with GERD, when should Baclofen or alginate-based therapies be considered, and which patient characteristics warrant caution when using these treatments?
Baclofen and alginate-based therapies are adjunctive, phenotype-directed options for actionable GERD symptoms refractory to optimized proton pump inhibitor therapy. Baclofen reduces transient lower esophageal sphincter relaxations and is most effective in regurgitation or belching predominant phenot...
With the latest hepatitis B guidelines and recent phase 3 trial of Bepirovirsen mentioning the utility of quantifying HBsAg levels, how have you incorporated HBsAg in your practice?
Since the first New England journal publication on Bepi (Yuen et al., PMID 36346079), which demonstrated functional cure in patients with less than 1,000 international units of surface antigen, we’ve been quantifying surface antigen in all of our hepatitis B patients. Almost all the large commercial...