Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
How would you approach the consideration of continuing or ceasing colonoscopy for colon cancer screening in a relatively fit man in his 80s without a history of polyps on prior colonoscopies?
For someone in his 80s who has received good screening and never had polyps, continuing colonoscopy brings little benefit. The risks and difficulties from the procedure become greater with age, so, for most older adults, stopping routine screening is usually the better option for geriatric care. Whe...
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 would you treat a patient with stage IE gastric MALT lymphoma with negative testing for H. pylori?
Standard of care treatment in these patients mostly includes local radiotherapy. You need to be certain that the patient is truly HP-negative; the gold standard for this is negative histopathology for HP. In patients with negative HP histology, you should still rule out HP with non-invasive measures...
Does recurrentor severe aspiration imply underlying oropharyngeal dysfunction despite a reassuring SLP/VFSS evaluation?
Attributing recurrent, clinically significant aspiration purely to the esophagus is mechanistically weak in the context of normal airway protective mechanisms. When the clinical picture is true macroaspiration, the coherent mechanisms are an oropharyngeal source with failed (often silent) airway pro...
Do 5HT4 agonists such as Metoclopramide actually lead to improvement in symptoms for patients with diabetes related gastroparesis?
Yes, sometimes when the gastroparesis is frequent or the symptoms are tough, I do use Reglan to help. By the time they wind up in the hospital, they are really willing to have me use anything on them that might help. I explain to every patient the side effects of Reglan, including tartive dyskinesia...
How do you distinguish cannabinoid hyperemesis syndrome from cyclic vomiting syndrome?
When you are seeing a patient with intractable vomiting, this is a good time to slow down and take a thorough history. Often, patients can provide key pieces of information that help you distinguish cannabinoid hyperemesis syndrome (CHS) from cyclic vomiting syndrome (CVS). CHS typically occurs in y...
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 factors push you toward upfront necrosectomy rather than step-up drainage in a patient with symptomatic walled-off necrosis after four weeks?
The indications for intervention on walled-off pancreatic necrosis are typically signs that the fluid collection has become overtly infected (causing abdominal sepsis), significant mass effect on adjacent organs, gastric outlet obstruction, or resultant abdominal pain and anorexia. If the patient is...
When do you pursue liver biopsy for assessment of DILI?
In the setting of an acute elevation of liver chemistry tests, DILI should always be considered in the differential diagnosis. If the serological workup for abnormal liver tests is unrevealing as well as abdominal imaging, expectant management should ensue with the discontinuation of any potential o...
What specific “stop rules” do you use during difficult native-papilla biliary cannulation (e.g., time, cannulation attempts, pancreatic duct wire passages/injections) to trigger an early change in strategy, such as precut or referral/escalation?
I would not say 'stop,' but, as you said, 'change' the strategy. After attempting for about 5 minutes and touching the papilla with the catheter you started with 4-5 times, even if the guidewire goes into the pancreatic duct once, I tend to use that as a double-wire technique and then place a pancre...