Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
How do you approach the treatment of reflux hypersensitivity in patients on PPI therapy?
Reflux hypersensitivity is defined by typical reflux symptoms with normal endoscopy and normal esophageal acid exposure, but positive symptom association with physiologic reflux events on pH testing. Because acid exposure is normal, escalating PPI therapy is usually not beneficial, and treatment ins...
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 recommend, based on current evidence, avoiding antimotility agents in patients with non-fulminant C. difficile infection who have no evidence of ileus?
I generally avoid their use based on the notions that diarrhea may contribute to the elimination of non-invasive GI pathogens and that impairment of intestinal motility could increase the risk of complications, such as toxic megacolon.The data and recommendations have not progressed beyond the follo...
What patient characteristics guide the selection of a step-up versus a step-down elimination diet strategy in the management of eosinophilic esophagitis?
It is a shared decision making between the Physician and the patient. The step-up approach requires fewer endoscopies and may be better tolerated and accepted by the patient. But again a detailed discussion with the patient is needed for any kind of diet strategy to work.
When starting GLP-1 R agonist therapy for weight loss purposes, how do you counsel patients on duration of treatment therapy?
I counsel people that I expect this to be lifelong therapy (similar to how we don't stop blood pressure medications when blood pressure comes down to normal on them because it will go back up, we don't stop GLP1RA when we get to our weight goals, as our weight will go back up when they are stopped)....
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...
What is your approach to terminal ileal structure in the setting of a new diagnosis of Crohn’s disease on index colonoscopy?
If there have been episodes of symptomatic obstruction or if there is proximal dilation on imaging, I would forgo any medical therapy and move straight to resection.
If a young patient with biopsy proven EOE is doing well on bid PPI, when would you consider switching to Dupixent in order to precent long term complications such as strictures?
If the patient is in proven histologic remission on PPI and the symptoms are well-controlled, then the patient has PPI-responsive EoE and can stay on PPI as maintenance therapy. There is no indication for switching to Dupixent in this scenario except for patient preference. There is no current evide...
What antibiotic prophylaxis do you recommend for a cirrhotic patient with an upper GI bleed, if any, in light of the recent meta-analysis published in JAMA Internal Medicine?
This study highlights the lack of high-quality data supporting the recommendation for antibiotic prophylaxis in cirrhosis patients with upper GI bleeding. At my institution, we usually recommend a short course of 3 to 5 days, though some clinicians extend it to 7 days. If there is ongoing bleeding, ...
Would you use upfront atezo/bev in a patient with HCC and untreated hepatitis?
In the case of a patient with untreated chronic hepatitis C, I would offer upfront atezo/bev, as long as hepatic function is appropriate. At our center, hepatitis C treatment is generally not offered to patients with advanced HCC. Interestingly, only 21% of patients treated with atezolizumab/bevaciz...