Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
In a young patient who was vaccinated against 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.
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 analgesic in patients with small bowel obstruction or ileus?
I prefer scheduled IV acetaminophen; if possible, IV ketorolac. At my institution, we also have an option for Butrans patches, as there is decreased effect on the gut. There is some evidence for IV lidocaine, which is also available. IV lidocaine is a reasonable opioid-sparing option to prevent post...
How do you decide between HIDA scan and MRCP when ultrasound and/or CT demonstrate gallstones but are equivocal for cholecystitis?
Best physiologic test using a fatty meal or Kinevac.
How do you decide when to use acid-suppressive medications for GI prophylaxis when patients are on prolonged corticosteroid therapy?
We only use acid-suppressive medications for GI prophylaxis in patients treated with corticosteroids when they have additional risk factors for upper GI bleeding. Risk factors include concomitant NSAID or antiplatelet therapy, history of GI bleeding or peptic ulcer, age over 60 years, prednisone dos...
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.
For a patient with acute pancreatitis who is on GLP-1 medication, would you attribute the pancreatitis to a passed stone/sludge or the GLP-1 medication itself?
I would be sure that there are no other obvious etiologies for acute pancreatitis, but the majority of cases of acute pancreatitis are due to biliary, alcohol, and smoking. Always look at the LFTs around the time the patient presents with acute pancreatitis, as an ALT >3x the upper limit of normal, ...
After confirming the patient is not on NSAIDs, how do you approach acute ileitis on biopsies in a patient without symptoms or with only mild loose stools?
Is diarrhea inflammatory? What is her level of calprotectin? A useful biomarker to follow. Aphthous ilieitis does not have risk features for progressive Crohn’s that, at least at this time, does not require an advanced agent. You can use symptomatic agents (loperamide, cholestyramine, etc.) to asses...
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...
How do you approach a low grade intra-cholecystic papillary neoplasm of the gallbladder without invasive component and reported surgical pathology with negative margins?
The patient is cured with a cholecystectomy. Heal with steel!