Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
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 (...
Would you begin semaglutide in a morbidly obese patient with intermittent elevations in ALT (100s) and with significant hepatic steatosis but without significant fibrosis?
How was fibrosis identified? Based on the information provided, if the rest of the serologic workup was negative for liver disease, I would be comfortable starting semaglutide. Its cross-disease benefits are likely to be highly impactful in someone we are assuming has MASLD. Liver biopsy would be us...
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...
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 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...
When do you consider scheduled antiemetics in hospitalized patients experiencing severe nausea?
The biggest problem I see is antiemetics given PRN when a patient has consistent nausea. The goal is to get above the nausea so that the patient begins to feel better. This is similar to how one treats pain. Thus, if a patient is taking an antiemetic more than once a day and has consistent nausea, I...
Under what circumstances do you give chemotherapy for a nondiagnostic pancreas biopsy that is suspicious for adenocarcinoma?
Assuming it is a localized pancreatic abnormality and no "metastases," I would not give chemotherapy as such. If anything, I would consider surgical removal, which will also give the exact diagnosis. To start, chemotherapy is not curative (maybe if it were a lymphoma!). There may be some way of doin...
Where does alpha-gal testing fit in your workup of a patient with nausea, vomiting, and/or diarrhea?
I routinely test for galactose-alpha-1,3-galactose (alpha-gal) in someone with recurrent hives. Lately, also someone with nausea. I have not been testing for this in those with diarrhea.
What interventions do you find helpful for the initial management of functional GI disorders in primary care?
TCAs seem to help modulate pain, particularly at low doses.