Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
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.
How would you approach diagnosis of a patient with recurrent episodes of abdominal pain, severe myalgias, low grade fevers and urticaria?
Without the mEFV variant, from a rheumatologist viewpoint, the differential includes IBD, a periodic fever syndrome such as FMF or FCAS, and MCAS. Therefore, I would consider that workup with genetic testing (anyone can send!), fecal calprotectin, and MCAS eval with A/I. I don't think of urticarial ...
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...
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...
How do you decide when to refer for gut-directed psychotherapy versus start pharmacotherapy in newly diagnosed IBS with prominent anxiety symptoms?
Pharmacotherapies like antispasmodics, antidiarrheal medications, or tricyclic antidepressants can be used to treat a specific symptom of IBS (e.g., diarrhea or abdominal pain). Gut-directed psychotherapy targets the entire gut-brain axis in dysfunction, treating multiple symptoms at once, as well a...
How many days prior to elective major surgery do you recommend holding oral GLP 1 R agonist therapy?
Zero. Or, I suppose, if you're having surgery early in the morning, one.This has gone back and forth, but the most recent guidance from the ASA (with other societies concurring) has been that most patients can continue their GLP medications as normal preoperatively, with higher-risk people being rec...
Does oral Wegovy have a worse side effect profile compared to its injectable version?
From a clinical standpoint, I would say that oral semaglutide does cause more nausea and other GI side effects than injectable semaglutide for comparable doses. I am not aware of any randomized trials looking at this question, but there are single-center retrospective studies corroborating my impres...
Are there any biomarkers that might indicate who might be responders to atezolizumab/bevacizumab for HCC?
Not at this time. Some preliminary studies are being done as ad hoc at this point and was not pre specified before the IMbrave study launching
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...
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 (...