Author Archives: ovmcwp

Intern Case Conference – Ascending Cholangitis

cirrhosis-s1-facts

Teaching Point

Common etiologies
- Alcohol
- Hepatitis C and B
- NAFLD
Complications
- Ascites: spironolactone 100mg/lasix 40mg
- SBP: ceftriaxone 2gm IV q24h
- Hepatic encephalopathy: lactulose, neomycin/rifaximin

Here is the powerpoint for today’s intern case conference on ACS: InternReport.ACS

Highlighted_Liver_crop

Thank you Dr. Reynolds for an excellent presentation on drug-induced liver injury

Teaching Points

Patterns of abnormal LFTS
- Hepatocellular: high AST/ALT w/mild elevation in alk phos
- Cholestatic: High alk phos w/ mild AST/ALT
Causes of hepatocellular injurry
- Alcohol: AST elevation greater than ALT
- Viral: ALT elevation greater than AST
- NAFLD/NASH: AST to ALT ratio typically 1
- Toxins: NSAIDS, abx, statins, anti-epileptic drugs
- Hereditary/autoimmune: hemochromatosis, autoimmune hepatitis, alpha-1-antitrypsin deficiency, Wilson’s disease
- Shock: high elevations in AST/ALT
- Non-hepatic causes: muscle disorders, thyroid issues, celiac disease, adrenal insufficiency, anorexia

Thank you Dr. Feng for an excellent presentation on the management of atrial fibrillation in the setting of acute de-compensated heart failure

Teaching Points

Important components of management: hemodynamic stability, rate control, anti-coagulation
Rate control agents: beta blockers, calcium channel blockers (not preferred in HF), digoxin and amiodarone (also an anti-arrhythmic)
Antiarrhythmics for afib are Class IC or III
- IC: flecainide, propafeonone
- III: amiodarone, dronedarone, sotalol, dofetilide
Anti-coagulation: indicated if CHADSVASc ≥ 2 (warfarin or newer agents, ie apixaban or rivaroxaban)

CAP

Here is the power point from today’s case conference on the diagnosis and management of Community Acquired Pneumonia.

Thank you Dr. Jang for an excellent presentation on granulomatosis with polyangiitis presenting as lower extremity edema from renal involvement.

Teaching Points:

GPA can involve multiple organs including nasal ulcers, cartiglage destruction, tracheal stenosis, alveolar hemorrhage, glomerulonephritis, leukoclastic angiitis
Diagnosis is made by biopsy and positive ANCA
Treatment involves 2 components: induction of remission and maintenance to prevent relapse. Induction is with steroids and rituximab or cyclophosphamide. Maintenance regimens include methoetrexate, azathioprine, rituximab, and tapering of glucocortidoids.

Further Reading:
Ritximab vs Cyclophosphamide for ANCA – Associated Vasculitis (RAVE trial)
Rituximab vs Azathioprine for Maintenance in ANCA-Associated Vasculitis (MAINRITSAN trial)
Azathioprine or Methotrexate Maintenance for ANCA-Associated Vasculitis (WEGENT trial)