GIM Week 8 Summary

Question 36

A 70 year old woman is brought into hospital by her son for severe weakness. The son reports that she has had a poor appetite for the past few weeks, has been losing weight, and has been complaining of abdominal pain, nausea, and “pain in her bones”. It was not until yesterday that she became increasingly weak and lethargic.

1. What clinical syndrome is this patient exhibiting?
   The patient in this scenario is experiencing a hypercalcemic crisis.
2. What are the two most common causes of the syndrome in patients?
   The two main causes of hypercalcemia are primary hyperparathyroidism and malignancy.
   • Carcinomas of the bronchus, breast, head/neck, urogenital tracts and multiple myeloma can be associated with hypercalcemia. The possible mechanisms for this are osteolysis or excretion of serum parathyroid-related protein (PTHrP), elevated serum 1,25-(OH)₂D, or nephrogenic cyclic AMP.
   • Other causes include medication and familial hypercalciuric hypercalcemia.
3. What is your immediate treatment of this patient? Intermediate treatment?
   Immediate management of this patient includes:
   • Stopping any medications that may be causing/exacerbating the hypercalcemia (if applicable)
   • Maintaining hydration with IV NS (to maintain ECF volume, GFR and renal calcium excretion)
   • Administering a loop diuretic (to aid in renal calcium excretion)

   Intermediate therapy includes:

   • Initiating bisphosphonate treatment for antiresorptive therapy (begin at the same time as immediate treatment)
   • Treat the underlying cause
     • Primary hyperparathyroidism – parathyroidectomy
     • Malignancy – treat the underlying cancer

Resources

1. Bushinsky DA and Monk RD. Calcium. Lancet. 1998;352:306-311.
2. Carroll MF and Schade DS. A Practical Approach to Hypercalcemia. Am Fam Physician. 2003;67:1959-1966.
3. Ziegler R. Hypercalcemic crisis. J Am Soc Nephrol. 2001;12 Supple 17:S3-S9.

Question 37

List 6 complications of cirrhosis.
Cirrhosis is the result of progressive scarring of the liver, secondary to one or several pathologic processes (commonly: Hepatitis B/C, alcohol, non-alcoholic fatty liver disease).

Six possible complications of cirrhosis are:

• Ascites
• Spontaneous bacterial peritonitis
• Hepatic encephalopathy (caused by metabolic abnormalities – can present with confusion and neuromuscular dysfunction (i.e. asterixes))
• Hepatorenal syndrome
• Esophageal varices/bleeding
• Coagulopathy

The Childs-Pugh score is a useful tool to determine the severity of a patient’s cirrhosis. The following factors are used to determine this score:

• Encephalopathy grade
• Ascites
• Total bilirubin level
• Serum albumin level
• PT/INR

How do you treat hepatic encephalopathy?
Treatment of hepatic encephalopathy involves:

• Lactulose – decrease levels of serum ammonia
• Rifaximin (can be used if hepatic encephalopathy is refractory to lactulose)
• Potassium (if hypokalemic – hypokalemia increases renal production of ammonia)

Diagnosis and management of hepatic encephalopathy should be rapid to prevent coma and death.

Resources

1. Heidelbaugh JJ and Bruderly M. Cirrhosis and Chronic Liver Failure: Part 1. Diagnosis and Evaluation. Am Fam Physician. 2006;74:756-762.
2. Heidelbaugh JJ and Sherbondy M. Cirrhosis and Chronic Liver Failure: Part II. Complications and Treatment. Am Fam Physician. 2006;74:767-776.
3. Vilstrup H et al. Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver. Hepatology. 2014;60:715-735.

Question 38

A 55-year-old man is admitted to hospital with fever, nausea, anorexia and jaundice. He admits to a 1-year history of IV drug use.

1. What is your differential diagnosis for this patient?
   Jaundice in an adult patient has a differential that includes hepatic, biliary and pancreatic causes. In conjunction with the patient’s other symptoms, the differential diagnosis includes:
   • Acute hepatitis A/B/C
   • Cholangitis
   • Cholecystitis
   • Pancreatitis
2. Assuming this is acute hepatitis B, what specific serological markers would you expect to see in this patient?
   Hepatitis B viral serological markers can assist in determining the acuity of a hepatitis B infection:
   • Acute infection: HBsAg positive, anti-HBc positive, IgM anti-HBC positive, anti-HBs negative
   • Chronic infection: HBsAg positive, anti-HBc positive, IGM anti-HBc negative, anti-HBs negative
   • Immunity due to vaccine: HBsAG negative, anti-HBc negative, anti-HBs positive
   • Immunity due to prior infection: HBsAg negative, anti-HBc positive, anti-HBs positive

   As the patient in this case has an acute hepatitis B infection, the following serological markers are expected:

   • HBsAg positive, anti-HBc positive, IgM anti-HBC positive, anti-HBs negative

Resources

1. Centers for Disease Control and Prevention. Interpretation of Hepatitis B Serologic Test Results. Retrieved from: http://www.cdc.gov/hepatitis/HBV/ProfResourcesB.htm.
2. Roche SP and Kobos R. Jaundice in the Adult Patient. Am Fam Physician. 2004;69:299-304.

Question 39

A patient on your ward is being treated with ceftriaxone for pneumonia. Two days after antibiotic administration, she begins to experience watery diarrhea, but no fever.Clostridium difficile PCR testing on a stool sample comes back positive. The patient’s CBC, lytes and creatinine are within normal limits.

1. What is your initial treatment for this patient?
   This patient has a mild C. difficile infection.
   The treatment indicated is Metronidazole 500mg PO TID for 10-14days.
   Second line treatment is Vancomycin 125mg PO QID for 10-14days.
2. How would your management change if the patient developed a fever, an elevated WBC count, and hypotension?
   A patient with C. difficile presenting with fever, an elevated WBC count, and hypotension is exhibiting severe/complicated C. difficile infection.
   The treatment in this case would be metronidazole 500mg IV q8h AND vancomycin 125-500mg PO QID.

Resource
Bagdasarian N, Rao K and Malani PN. Diagnosis and treatment of Clostridium difficile in adults: a systemic review. JAMA. 2015;313:398-408.

Question 40

What are the Well’s criteria for pulmonary embolism?
Well’s criteria:

• Clinical signs of DVT (3 points)
• Alternative diagnosis less likely than PE (3 points)
• Heart rate >100bpm (1.5 points)
• Immobilization or surgery within 4 weeks (1.5 points)
• Previous DVT/PR (1.5 points)
• Hemoptysis (1 point)
• Malignancy with ongoing treatment or palliative (1 point)

Probability of PE based on score:

• <2 Low probability
• 2-6 Moderate probability
• >6 High probability

What investigations would you order for a suspected PE?
If there is a high suspicion of pulmonary embolism, a stat ECG, troponin, CK, and CT with pulmonary angiogram should be ordered.
What is your initial treatment for a PE?
Initial treatment for a pulmonary embolism includes:

• Supplemental O₂
• Anticoagulation (if hemodynamically stable)
  • Low molecular weight heparin
    • Enoxaparin 1mg/kg q12h or 1.5mg/kg daily for 5-10d
    • Tinzaparin 175U/kg daily for 5-10d
    • Dalteparin 100IU/kg q12h or 200IU/kg daily for 5-10d
    • Nadroparin 86 IU/kg q12h or 171 IU/kg daily for 5-10d
  • Fondaparinux is another option
• Thrombolysis (if hemodynamically unstable/massive PE)
  • tPA 100mg IV over 2hrs

Resources

1. Wells PS, Anderson DR and Ginsberg J. Assessment of deep vein thrombosis or pulmonary embolism by the combined use of clinical model and noninvasive diagnostic tests. Semin Thromb Hemost. 200;26:643-656.
2. Konstantinides SV et al. 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J. 2014;35:3033-3073.