Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
Do you escalate therapy based on persistent gastric eosinophilia in a patient with eosinophilic gastritis improving symptomatically on corticosteroids?
It obviously depends on steroid dose and duration. My instinct, however, when dealing with such potent therapy as corticosteroids, and in view of symptomatic improvement, would be to hold the course a bit longer before being in a rush to escalate.
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...
Would you consider octreotide as an adjunctive therapy for patients experiencing an acute life-threatening hemorrhage, outside of standard indications such as variceal or AVM bleeding?
In very selective scenarios, when the patient is experiencing an acute life-threatening bleeding while variceal or AVM bleeding remains on the differential, yes, I would consider octreotide as an adjunctive therapy, but only as a bridge to definitive diagnosis and treatment and not as a substitute f...
Do you consider off-label dupilumab rather than dietary therapy in a patient with eosinophilic gastritis needing long-term disease control?
This is not a bad choice, but has the patient failed or been intolerant to budesonide? We give that when they chew the capsule for immediate release.
Do you recommend CBD cessation prior to screening of liver enzymes?
CBD increases liver enzymes. In a study, it took 1-2 weeks to normalize after cessation. Would recommend ideally 2 weeks, but a minimum of 1 week to remove the noise caused by CBD that may lead to an extensive and possibly unnecessary workup.
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...
Would you avoid risankizumab in a patient with stricturing Crohn’s complicated by granulomatous bronchiolitis with stenosis who had to stop ustekinumab due to hemoptysis?
Unless there had been a rapid and dramatic beneficial response of the Crohn’s disease to ustekinumab, I would have little appetite for trying another IL-blocker. A different mechanism, like JAK, might be worth trying, but the serious pulmonary complication probably warrants steroid therapy. One coul...
Should platelet transfusions be considered for anti-platelet agent reversal in patients with major bleeding?
Patients on plavix and/or aspirin are at risk for bleeding whether in relation to surgery or bleeding from the gi tract. Much like the management of patients on anticoagulation temporary reversal of antiplatelet drugs is only achieved by normalizing platelet function. This is the same principle used...
What therapies would be considered safe and effective in pregnant patients with EoE?
Management of EoE during pregnancy should be individualized using a shared decision-making model. Food elimination can lead to remission, but some patients have difficulty following the diet. Proton pump inhibitors, such as omeprazole and esomeprazole, and swallowed budesonide are safe during pregna...
How do you approach the management of older adult patients with coronary artery disease on aspirin who have developed intermittent diverticular bleeds?
This is a tough clinical scenario that comes up often in older adults. You will often have subspecialists involved and will need to adapt your approach to their management and communication styles. Generalists can add value here by looking at the whole picture and figuring out what matters most to t...