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...
Would you consider use of prophylactic antibiotics in patients admitted with decompensated cirrhosis with AKI with Cr>1.2, with ascitic fluid protein < 1.5 without SBP and / or hyponatremia/Bili >3 ?
Is this in generalized cases or cases of GIB? if GIB, yes i would consider it. if just in generalized cases, there is no real role for empiric abx
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...
What is your approach to work up and management of a patient with advanced HIV and poor adherence to therapy presenting with dysphagia and fever?
I would first do an HPI (is the dysphagia for both liquids and solids?), then a quick physical exam, with a full set of vital signs. In terms of basic blood work, I would get a CBC and BMP, liver function tests, a set of blood cultures, a chest x-ray, along with a viral load and CD4 T cell count, wh...
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...
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...
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.
How do you balance the need for diuretics from a volume perspective (Ex: ascites, edema) in decompensated cirrhotic patients and progressive renal dysfunction?
There is no discrete answer to this question. Much depends on the overall goal of care. For a transplant candidate, higher creatinine may be needed for transplant access and be tolerated, but risk need for post-transplant RRT. If goals are palliative, symptom control supersedes renal function.
What are your next steps for a patient with gastritis on histology without NSAID use and H. pylori negative?
Gastritis is often reported on histopathology, but without more specifics from the pathologist, it has limited clinical utility. In my experience, qualifying the pattern and extent of gastritis can provide more guidance on subsequent management. The endoscopist should assess and document the visual ...
What is your preferred first-line regimen to treat a severe or fulminant C difficile infection?
IV vancomycin and PO Flagyl are the easiest combination to get for a hospitalized patient. I’ve had much experience with this, and it works very well. IV vancomycin and PO Flagyl as initial treatments in the hospital is my preference. This is before I go onto stronger drugs, with those requiring al...