Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
How would you approach the management of an incidentally detected subcentimeter nodule located just below/adjacent to the GE junction in a patient without Barrett’s, that is found to harbor high-grade dysplasia (HGD) on pathology following EMR?
I think this depends on the pathology and whether margins were clearly negative. If there is HGD on the margin, I think pt would need further resection, likely ESD, to ensure no dysplastic tissue remains. In addition, careful inspection of the esophagus and stomach under HD-WLI, as well as NBI or BL...
What is the recommended surveillance approach for gastric intestinal metaplasia in patients without gastric cancer risk factors?
For U.S. patients with gastric intestinal metaplasia (GIM) without high-risk features, both the AGA and the ACG recommend testing for and eradication of Helicobacter pylori infection as the primary intervention for gastric cancer prevention, while routine surveillance endoscopy is not recommended in...
How long do you typically treat patients with phentermine for weight loss and what clinical markers do you follow?
Phentermine has been available since 1959 and remains an affordable and effective medication option added to a full lifestyle-based weight management plan. In people who are generally healthy and without contraindications to the medication, I have had patients used in at least intermittently for sev...
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?
Yes, this is applicable to patients who are on single agent immunotherapy, since the atezo/bev combination carries different mechanism of synergistic potential than single agent immunotherapy. Notably, currently approved second line agents are indicated after progression on sorafenib, however, curre...
What is your preferred management for large esophageal varices with red wale marks found on screening EGD in a patient with decompensated cirrhosis, no prior GI bleeding, and good adherence to medical care?
You're describing high-risk varices, which need to be treated somehow. Guidelines do suggest NSBB and banding as an alternative if patients can't tolerate NSBB, so if you feel this patient may not be able to undergo subsequent EGDs every 2-4 weeks until eradicated, then suggest NSBB.
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...
Do you routinely give prophylactic antibiotics prior to ERCP for biliary obstruction in light of recent studies suggesting a reduction of periprocedural infection?
I did not use to give antibiotics routinely prior to ERCP, and it seemed post-ERCP antibiotics were given at the discretion of the advanced endoscopist, but the results of this meta-analysis will likely change my practice so that I'll give all patients a dose of Ceftriaxone prior to the procedure to...
What is your treatment approach to a patient with budesonide refractory microscopic colitis and multiple sclerosis?
First job is to be sure the colitis is not attributable to any medication, particularly ocrelizumab. Meanwhile, have you given an adequate trial of bismuth?
How do you decide when to use acid-suppressive medications for GI prophylaxis when patients are on prolonged corticosteroid therapy?
Consideration of risk factors is important. Routinely, someone without these risk factors, and if getting a short burst of steroids, the GI prophylaxis is not given. PPIs carry certain risks, including increased risk of C. Diff infection or even pneumonia. So, they should be avoided if not indicated...
In a young patient who was vaccinated to chickenpox as a child (no previous varicella infection) should the patient receive a shingles vaccine prior to starting Rinvoq?
Yes. The vaccines are different and current vaccine is to prevent zoster for patients who have been previously exposed to varicella or vaccinated for varicella.