TIPS

Transjugular Intrahepatic Portosystemic Shunt

• Treatment for patients who bleed from portal hypertension
• Limited by high incidence of stent stenosis or thrombosis in first year
• Effective in reduction of refractory ascites, but associated with increased hepatic encephalopathy (vs serial paracentesis)

LVH EKG criteria

1: R aVL + SV3 >25 (men) or >20 (women)

2: SV1 + R V5 or 6 > 35, RV5 or 6 > 25

3: R aVL > 8

4: RV6 > 18

5: VAT > 0.05s

These criteria have high specificity (in the 90s) but low sensitivity (10-25%)

Cheyne-Stoke Respiration

Periodic respiration/cyclic respiration: hyperventilation and hypocapnea followed by recurrence of apnea

• common in advanced heart failure
• associated with low cardiac output
• decreased sensitivity of respiratory center to arterial CO2

Diuretics

Loop Diuretics (Furosemide)

• acts in thick ascending limb of loop of Henle to block the Na+/K+/2Cl- co-transporter, preventing reabsortion of Na, K, Cl
• increase fractional excretion of Ca++ up to 30%, increase fractional excretion of Mg++ up to 60%
• used to tx hypercalcemia, edematous states ie CHF

Thiazides and Thiazide-like Diuretics (chlorothiazide)

• acts in distal convoluted tubule to block coupled Na and Cl reabsorption
• increase excretion of Na, K, Cl but less potently than loop diuretics
• reduce Ca++ excretion
• used in uncomplicated hypertension, less useful in edematous states

Distal Potassium-Sparing Diuretics (spironolactone, amiloride)

• acts in cortical collecting duct prinicpal cells on aldosterone-sensitive Na+ channel
• reduced excretion of K+, Ca++, Mg++
• first line for cirrhotic ascites, also can be used in heart failure w/ systolic dysfunction, weak diuresis so commonly used in combination with a loop/thiazide diuretic to decrease K+ loss, increase diuresis in refractory edema

Carbonic Anhydrase Inhibitors (acetazolamide)

• act in proximal tubule to inhibit bicarbonate absorption
• transient, brisk alkaline diuresis
• useful in edema w/ metabolic alkalosis to help restore acid-base balance

Osmotic Diuretics (Mannitol)

• freely filtered but poorly reabsorbed
• acts in proximal nephron and thin loops of Henle to prevent urinary concentration

Adrenal Insufficiency

Primary Adrenal Insufficiency (Addison's)

• caused by autoimmune, infectious (TB, cryptococcus, CMV, pneumocystis), iatrogenic (bilateral adrenalectomy), or metastatic (lung, breast) etiologies
• clinical features related to lack of cortisol: GI symptoms (anorexia, nausea/vomitting, abdominal pain), hypoglycemia, hypotension, hyperpigmentation, intolerance to physiologic stress
• clinical features related to lack of aldosterone: hyponatremia and hypovolemia-->decreased cardiac output and renal perfusion, syncope, shock, hyperkalemia
• tx in acute crisis: several liters of IV fluids (D5NS), IV hydrocortisone, tx underlying condition
• chronic tx: daily oral glucocorticoid, daily mineralocorticoid

Secondary Adrenal Insufficiency

• Causes: long term steroid therapy + illness/trauma
• clinical features: same as above except that hyperpigmentation and hyperkalemia are not seen because ACTH is low, and aldosterone is normal
• tx: same as above except that only glucocorticoid supplementation is necessary

Heart sounds--gallops

Order of heart sounds: S4-->S1-->S2-->S3

S3

Occasionally heard in healthy children or adults, esp athletes

Occurs in dilated ventricles, for ex:

large VSD

CHF

volume overload

S4

Usually pathologic

Occurs with decreased ventricular compliance , for ex:

Normal (especially athletes)

Hypertensive

Coronary artery disease

Aortic stenosis

Restrictive cardiomyopathy

Chronic Pain Treatment

Chronic pain treatment optimally involves a combined pharmaceutical and non-pharmaceutical approach. Pharmaceutical options include a range of classes:

• Opioids, side effect: sedation, constipation, respiratory depression, abuse potential
• NSAIDS: GI ulcers, bleeding, renal impairment
• Serotonin agonists: MI, stroke, peripheral vascular occlusion
• Antiepileptics: sedation, dizziness, cognitive impairment
• Antidepressants: Cardiac arrhythmia, sedation, nausea, dry mouth, constipation, sleep disturbance

Some commonly used pharmaceuticals include:

• Tramadol (ultram): 250-300 microgm q 6hr, binds mu-opioid receptors and inhibits the noradrenaline reuptake inhibitor, has addictive/abuse potential
• Toradol (Ketorolac): 10 mg q 6hr, NSAID, risk of gastritis after 5-7 days
• Vicodin: 5/500 or 7.5/750, hydrocodone and acetaminophen, formulations which use NSAID instead of acetaminophen are also available (Vicoprofen)

Severely elevated transaminases

Severely elevated ALT/AST (>10000) indicates extensive hepatic necrosis. Common causes include:

• ischemia, shock (prolonged hypotension/circulatory collapse)
• acute toxic insult (acetaminophen toxicity, mushrooms: Amanita phalloides)
• Severe viral hepatitis

This is in contrast to:

• moderately elevated ALT/AST (high hundreds to thousands): acute viral hepatitis

• mildly elevated ALT/AST (low hundreds): chronic viral hepatitis, acute alcoholic hepatitis.

Leukopenia

Leukopenia: WBC<4-4.5X10^3/mm3
Neutropenia: most common cause of leukopenia, classified based on risk of overwhelming infection as

• mild: 1000-1500 cell/mm3
• moderate: 500-1000 cell/mm3
• severe: <500>

Mild/moderate neutropenia can be tx on outpatient basis if a clear, reversible source is identified and no clinical findings are seen. Severe neutropenia with fever should be admitted with panculture and panimaging.

Mechanisms of leukopenia

1. bone marrow injury: drugs, radiation, toxins, infections (mumps, measles, malaria, influenza, parvo, TB, typhoid, tularemia, HIV, EBV) , infiltrative disease of bone marrow (lymphoma, leukemia, and mets from lung, breast, prostate, stomach CA)

2. maturation defect : folic acid/B12 deficiency, neoplasm (ie acute myeloblastic leukemia)

3. sequestration: hypersplenism

4. destruction: autoimmune (ie Systemic lupus erythematosus)

Lymphopenia

lymphocyte count <2x10^3>

Common causes: HIV, corticosteroids, Hodgekin's lymphoma, multiple myeloma, protein-calorie malnutrition

Wernicke Encephalopathy

• Sx: confusion, ataxia, opthalmoplegia
• Mechanism: thiamine deficiency
• Affected population: alcoholism, AIDS, hyperemesis, bowel resection/gastric bypass
• Tx: thiamine c/ dextrose, often given as banana bag with folic acid and Mg sulf
• can be worsened by glucose, so glucose should not be given prior to thiamine

Myasthenia vs. Lambert-Eaton

Myasthenia Gravis
Sx: fluctuating weakness of commonly used voluntary muscles, weakness increased by activity

• diplopia
• ptosis
• difficulty swallowing
• respiratory and limb muscles may be involved

Dx: Tensilon test (edrophonium chloride test): short acting (min) anticholinesterase, transiently improves symptoms of Myasthenia gravis

Associated conditions: thymic tumor, thyrotoxicosis, rheumatoid arthritis, lupus erythematosus

Mechanism: anti-Ach-R antibodies made

Tx: 1st line: anticholinesterases (symptomatic), recommended if pt <60>

Admit indications: acute exacerbation, plasmaphoresis, thymectomy, starting corticosteroids

Interactions: aminoglycosides worsen symptoms

Lambert-Eaton

sx: variable weakness, improved with activity

• dysautonomic symptoms present

associated conditions: h/o malignant disease (small cell carcinoma)

Mechanims: antibodies against voltage gated Ca++ channel

Tx: combined plasmaphoresis and immunosuppressive therapy (prednisone, azathioprine), tx underlying malignancy, response to anticholinesterases is variable