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...
In patients with microscopic colitis, what do you recommend on stopping SSRIs?
First, make sure the problem is not NSAIDs, PPIs, or statins. Second, remember that the evidence linking SSRIs to microscopic colitis is not iron-clad. Third, if you want to do a trial of a different class of antidepressant, the evidence linking SNRIs to microscopic colitis is even less consistent.
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...
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.
Is there a specific triglyceride level at which you discourage patients with metabolic syndrome from starting GLP-1R agonist therapy due to the risk of pancreatitis?
Overwhelming data show that acute pancreatitis is not directly due to GLP-1 use but rather the indirect effect of rapid weight loss leading to cholelithiasis and subsequent acute biliary pancreatitis in GLP-1 users. Hypertriglyceridemic pancreatitis is rare even among those with elevated TG levels (...
What is the role of inebilizumab in the maintenance treatment of IgG4-related disease?
Inebilizumab may play an important role in the maintenance treatment of IgG4-related disease (IgG4-RD), particularly in patients at high risk for relapse. These are typically patients with multi-organ involvement and elevated serum IgG4 levels who initially respond well to corticosteroids but tend t...
For an adult patient with newly diagnosed IBD with no co-morbidities who requires first step-up to biologics or other “advanced therapy,” would you routinely start with an anti-TNF (+/-antimetabolite), or--if insurance let you do anything you wanted—would you rather start with something else?
Recall that the first biologic you start will be the most effective. Because of the safety profile, I would start a selective anti-interleukin-23. The advantage of Tremfya is an all-subcutaneous Q induction, but Skyrizi would be fine as well.
In patients with MASLD and F2–F3 fibrosis, would you initiate Resmetirom even if they are not making active lifestyle changes?
Yes, many patients had an underlying metabolic disorder that is difficult/impossible to address with lifestyle interventions alone and will go on to progress in their liver disease if left alone. Now with the approval of Semaglutide in August 2025 by the FDA and the approval of Resmetirom, we have t...
In patients treated with infliximab, do rates of immunogenicity vary based on underlying disease (RA, IBD, sarcoidosis, etc) and/or baseline disease activity?
Yes, rates of infliximab immunogenicity appear to vary based on underlying disease, with evidence showing higher rates for RA than IBD and spondyloarthritis, and tend to increase with higher baseline disease activity. Most patients tend to develop anti-drug antibodies within the first year, but this...
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.