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241 Cards in this Set
- Front
- Back
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acid fast oocyste
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Cryptosporidium parvum
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Protozoa
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Entamoeba (bloody)
Giardia Balantidium (bloody) Isospora Cryptosporidium Cyclospora Microsporidia |
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Metazoa
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Pinworm
Roundworm Hookworm Whipworm Threadworm Tapeworm Schistosomes Trichinosis Flukes |
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Protozoa
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single cell
cyst form ** |
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Entamoeba histolytic***
in US |
****camper, hikers
also can be passed in day cars, mental hosp, prison 3rd world countries **Amebic dysentery, ss: bloody diarrhea, lots of PMNs, fever, no GNRods **food born in developing countries **world population- second only to malaria **invasive --PMN's in stool !!!!!!!!! on exam --(how does it cause diarrhea -- invades mucosa ) |
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lifesycle of ent histolitica
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trophozoite -is active form
can't survive in environment |
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ent histolitica , pathophys
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hepatomegaly , invades liver
we transient flora that are anemia, (come and go) looks like ent histolitica ***will see flask shape lesions .. get in and multiply .. leakage into gut lumen |
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number 1 cause of parasitic blody diarrhea
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E. histolytica
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E. histolytica diagnosis
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Elisa
history is key - camping flask shaped lesion |
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E. histolytica Tx
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Paromomycin is DOC for noninvasive disease
Metronidazole is DOC for symptomatic, invasive disease metro , has to be followed up with Paro |
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Giardia lamblia
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camper
beaver fever Sylvatic distribution (streams, lakes) aka: Giardia intestinalis Lamblia intestinalis in Europe fecal -oral transmission fomites: day care ***watery dirrhea , malabsorption, steatorhea |
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Giardia lamblia lifecyle
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cyst is ingested
horseshoe crap looking, flagella looks similar to Trichimonis (STD-wont cause steatorhea) malabsorption syndrome*** is most common board scenario parasites are persistent********with diarrhea |
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Giardia lamblia dx and tx
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stool exam - may show cyst form
boil water , but can survive in chlorinated water stomach acid can handle it Metronidazole, tinidiazole |
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Balantidium coli
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bloody dirrhea --only other ameoba that will cause this
Pigs*** hadling pigs is a risk factor case scenario---hunting boars .... vets blood and pus ********* ova not seen ----so not a worm -- all worms have eggs.. |
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Cryptosporidium
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One of most common water-borne diseases (Giardia)
Stable in environment (Oocyst = infectious form) Resistant to chlorination |
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C. parvum
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Contaminated water supply
>400,000 infected; 100 deaths there is a homosexuall transfer infects cells , but does not really cause bloody diarrhea with pus *****ACID FAST OOCYST |
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C. parvum- in AIDS patients
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50 + stools a day
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C. parvum tx
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Treatment: replace fluids, electrolytes
Nitazoxanide for immunocompetent pts |
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another acid fast stain
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Isospora belli
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Isospora belli
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also causes malabsorption syndrome
**JUST LIKE GIARDIA STAINS ACID FAST more common in gays and AIDS **oral-anal contact |
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Isospera tx
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TMP-SMX is DOC
Pyrimethamine with folinic acid |
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imported food...
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Cyclospora cayetanensis
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Cyclospora cayetanensis
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Watery diarrhea (explosive)
Raspberries from Guatemala Basil from Mexico *****ACID FAST Flurescent under UV lamp |
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Microsporidia
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found in water, mud puddles, etc.
In IC pts (AIDS) Chronic watery diarrhea, weight loss, abdominal pain, nausea, and vomiting Diagnosis: microscopy TEM (gold standard, expensive), IFA, PCR |
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dessiminated strongiliodyis case
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83 old with COPD and adenocarcinoma
Wet mount– shows Lungs affected.. By a worm Can disseminate all through body .. Threadworm |
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Metazoa
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All parasites that are not protozoa (multicellular)
Helminths: worms Nematodes (roundworms), Trematodes (flukes), Cestodes (tapeworms) Arthropods: crabs, insects, ticks, etc. |
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Nematodes
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roundworms
common in southern states have to ID using eggs |
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Pinworm
who get it ? who's dirty ? |
kids
Ingestion of eggs Eggs are ‘sticky’ Fomites, sexual contact crawl out at night happens in Erie OPP faculty--- got from a patient ****** sticky --- touch doorknob, can transmit head-lice-wash everything .... |
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pinworm dx
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Diagnosis: cellophane tape method
Clear adhesive cellulose tape applied to anal area Early morning before bathing or defecation Repeated examination (3 d) |
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pinworm tx
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treat whole family !!!
Treatment: pyrantel pamoate is DOC Mebendazole |
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Roundworm
Ascaris lumbricoides |
get eggs , eat someone else poop, eat eggs
bolus of worms expelled **** symptoms: can migrate to liver .. hepatomegaly .. |
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dx of Ascaris lumbricoides
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knobby coated, bile stained , oval shaped eggs
Treatment: albendazole is DOC |
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Toxocariasis roundworm
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Eggs ingested, larvae hatch and get ‘lost’
Cannot follow normal lifecycle in human Worms migrate through tissues |
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Toxocariasis roundworm ss
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Larvae can penetrate any tissue
Lungs, heart, kidney, liver, skeletal muscle, eyes, CNS most affected Bleeding, eosinophilic granulomas, necrosis |
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Toxocariasis roundworm dx
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Diagnosis: ELISA, *****eosinophilia, exposure to dogs/cats
Diagnosis of eggs in pet feces Eggs not found in human feces Treatment: albendazole is DOC |
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eosinopjhilia
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can also be seen with toxacara
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whipworm
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southern US
most are asymptomatic with this Fecal-oral transmission Found worldwide <0.1% prevalence in U.S. Southern Appalachian range and Gulf coast states |
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whipworm ss
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can cause constipation ****
bloody diarrhea Trichuris dysentery syndrome in heavy infections Bloody mucoid diarrhea, small frequent stools, anemia, and growth retardation*** and rectal prolapse |
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dysentery
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shigella
whipworm Entamoeba |
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dx and tx of whipworm
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History of travel to endemic area
Microscopic examination of stool *****Barrel (football) shaped eggs, plugged ends |
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hookworms
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Ancylostoma duodenale: old world hookworm
Necator americanus: new world hookworm step on .. dont go out barefoot ... in the south |
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hookworm ss
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Itching, localized maculopapular eruption
Low-grade fever may occur Mild cough, wheezing when worm in lungs Late symptoms (20-100 worms) Nausea, vomiting, diarrhea Microcytic, hypochromic anemia Fatigue and dyspnea |
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Ancylostoma braziliense
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Roundworm ---- puppies – lick their butt
Then lick your face Go to gut These ones you step on They don’t know where to go … at risk : beach , and sandbox-- like sandy soil ******* |
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threadworm
patient presented to millcreek |
eggs hatch in the body *** only one that does ?
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Trichinosis
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Larvae ingested in undercooked meat
Pork, *******bear (meat), fox, walrus meat Carnivorous wild animals |
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Trichinosis
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likes to go to eyes - periorbital edema
eosinophilia |
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Anisakiasis
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round worm
really fast symptoms sushi ******* netherlands ***** herring, not cooked.. south america worms get in fish , and you eat fish within hours of eating.. super fast anaphalaxis to worms |
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what causes eosinophila
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?
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Operculated eggs
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means a lid on the egg
either a fluke or a tapeworm helps it differ from worm or tapeworm |
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Trematodes
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Flat, leaf-shaped worms, larger than nematodes
Most hermaphroditic Except schistosomes All flukes have clam or *****snail intermediate host |
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swimmers itch
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schistosomes
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Giant Intestinal Fluke
Fasciolopsis buski |
SE asia
get from eating water chesnuts can cause malabsorption syndrome |
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liver fluke :
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Fasciola hepatica – sheep liver fluke
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most common cause of cholioangiosarcoma - GOljan
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Clonorchis sinensis
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eosinopila
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worms
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Schistosomes
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Schistosoma haematobium (bladder)-cancer
Hematuria S. japonicum (bowel) Occasional bloody diarrhea S. mansoni (bowel) Bloody diarrhea |
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lung fluke
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Only worm that lays it’s eggs in the sputum
Rust colored sputum |
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Schistosomes: Clinical Disease
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Acute disease (Katayama syndrome)
May occur wks-mos after initial infection Fever, chills, cough, urticaria, abdominal pain, diarrhea, eosinophilia Possibly due to release of parasite antigens & immune complex formation |
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Bloody diarrhea (S. mansoni mostly)
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Associated with “clay pipestem fibrosis”
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Schistosomes,
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Praziquantel is DOC
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Cestodes
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segmented body
Proglotids identified operculated eggs ************= tapeworm these eggs are not diff |
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Pork Tapeworm
Taenia solium |
cysticircosis *****
Abdominal discomfort, diarrhea, indigestion praziquantel is DOC Diagnosis: ****proglottids (adult worm only) and eggs in feces Eggs identical to beef tapeworm |
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Neurocysticercosis
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Hydroencephalitis, meningitis, nerve damage, seizures (epilepsy), visual defects (eye)
ring enhancing lesions - (just like toxo) |
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Fish Tapeworm
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*****megaloblastic anemia assocition
jewish old ladies ---- gefelter fish Associated with depleted serum vitamin B12******* Treatment: niclosamide Praziquantel alternative Vitamin B12 supplementation |
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Echinococcus spp
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Cause ****hydatid cyst disease
sheep disease.. get cysts in lungs and liver |
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metronidazole
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safe in preggers
DOC for Trich |
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dx of Giardia
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stool study
metronidazole |
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inflamation in cecum
liver abcesses |
Entamoeba histolytica
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**** stevens’ johnson syndrome ***
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Tinidazole causes it
rare |
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Babesiosis (Babesia microti)
(tick vector) |
Babesiosis is caused by hemoprotozoan parasites of the genus Babesia. Babesia microti and Babesia divergens have been identified in most human cases
symptoms: in immunosuppresed patients Treatment with clindamycin* plus quinine or atovaquone* plus azithromycin* are the options. exchange transfusion has been used in severely ill patients with high parasitemias. *****Maltese cross ******** in RBC |
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Trypanosoma cruzi (Chagas disease)
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Cardiac disease usually begins with conduction abnormalities such as right bundle branch block and/or left anterior fascicular block, followed by dilated cardiomyopathy
GI : esophagus Tx: ***** Nifurtimox and benzidazole |
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Trypanosoma brucei (African Sleeping Sickness
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Tsese fly
meningoencephalitic stage, invasion of the central nervous system can cause headaches, somnolence, abnormal behavior, and lead to loss of consciousness and coma |
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Nitazox-anide (Alinia)
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USE — ******Treatment of diarrhea caused by Cryptosporidium parvum or Giardia lamblia
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Nitazox-anide (Alinia)
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MECHANISM OF ACTION — Nitazoxanide is rapidly metabolized to the active metabolite tizoxanide in vivo. Activity may be due to interference with the pyruvate:ferredoxin oxidoreductase (PFOR) enzyme-dependent electron transfer reaction which is essential to anaerobic metabolism. In vitro, nitazoxanide and tizoxanide inhibit the growth of sporozoites and oocysts of Cryptosporidium parvum and trophozoites of Giardia lamblia.
inhibit growth of oocyte |
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Cyclosporiasis (Cyclospora cayetanensis)
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**watery diarrhea
The recommended treatment for cyclosporiasis is a combination of two antibiotics, trimethoprim-sulfamethoxazole*****, also known as Bactrim, Septra, or Cotrim. Supportive measures include management of fluid and electrolyte balance, and rest. |
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(Microsporidia)-rare-not on test
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Albendazole is the drug of choice
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Atovaquone (Mepron)
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Acute oral treatment of mild-to-moderate Pneumocystis jiroveci, (formally carinii) pneumonia (PCP), in patients who are intolerant to bactrim
Prophylaxis of PCP in patients intolerant to co-trimoxazole Treatment/suppression of Toxoplasma gondii encephalitis Primary prophylaxis of HIV-infected persons at high risk for developing Toxoplasma gondii encephalitis ***PCP pneumonia |
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Leishmaniasis
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female sandfly
2 types: Cutaneous leishmaniasis is characterized by one or more cutaneous lesions on areas where sandflies have fed. Persons have one or more sores on their skin that often end up looking like a volcano, with a raised edge and central crater Visceral leishmaniasis usually have fever, weight loss, and an enlarged spleen and liver. Some patients have swollen glands. Patients usually have anemia, low white blood cell count, and low platelet count. tx: sodium stibogluconate , under investigation |
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Pneumocystis jiroveci
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symptoms - fatique, pain , hiv-normal chest x-ray .. may just have cough
HIV - prsents with pneumothorax**** ****Treatment and prophylaxis with trimethoprim-sulfamethoxazole (TMP-SMX) is the initial drug of choice for both intravenous and oral therapy |
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Pentamidine
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Treatment and prevention of pneumonia caused by Pneumocystis carinii (PCP)
not common ****adverse reactions .. Adverse reactions occur in up to 70 percent of patients and include nausea, taste disturbance, cardiac arrhythmias, hyperkalemia, nephrotoxicity, pancreatitis, hypokalemia, hypocalcemia, hypoglycemia, and hyperglycemia *****permanet insulin sens diabetes so, use Bactrim |
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Pyrimethamine (Daraprim)
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malaria proph
Pyrimethamine (Daraprim)**** |
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Sulfadiazine
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have to compliment with folate
USE — treatment in toxoplasmosis DOSING Toxoplasmosis: Oral: 2-6 g/day divided every 6 hours in conjunction with pyrimethamine 50-75 mg/day and with supplemental folinic acid (DOC’s) |
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Toxoplasma gondii (Toxoplasmosis)
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First-line therapies for cerebral toxoplasmosis include pyrimethamine plus sulfadiazine (DOC) or pyrimethamine plus clindamycin.
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Malaria
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depends where people are going
severe: Quinidine gluconate plus one of the following: Doxycycline, Tetracycline, or Clindamycin |
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Metronidazole (Flagyl) uses ?
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protozoal infections in the following conditions: Amebiasis, symptomatic and asymptomatic trichomoniasis, giardiasis
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Trichomonas vaginalis, Trichomoniasis
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Trichomonas vaginalis, a flagellate, is the most common pathogenic protozoan in industrialized countries.
-sex -purulent discharge -wet mount DOC = metronidazole |
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Metronidazole (Flagyl)
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-disulfuram like rxn
nausea -12% -peripheral neuropathy -dont take alcohol after the dose for 24 hrs |
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Giardia tx ?
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metronidazole
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tx for intestinal amebiasis
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Paromomycin (Humatin
MOA: interferes with bacterial protein synthesis by binding to 30S ribosomal subunits (a nonabsorbable aminoglycoside) |
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tx for Entamoeba histolytica ?
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paromomycin is the drug of choice
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Tinidazole (Tindamax)
not often used but can cause... |
Treatment of trichomoniasis caused by T. vaginalis
Treatment of giardiasis caused by G. duodenalis (G. lamblia) **** stevens’ johnson syndrome *** what else causes this ? Treatment of intestinal amebiasis and amebic liver abscess caused by E. histolytica |
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Babesiosis is caused by hemoprotozoan parasites of the genus Babesia. Babesia microti and Babesia divergens have been identified in most human cases
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Treatment with clindamycin* plus quinine or atovaquone* plus azithromycin* are the options.
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P= R x F
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Portal hypertension can result from:
increase in resistance to portal flow and/or increase in portal venous inflow |
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anatomy changes with cirrhotic liver ?
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distorted sinusoids , leads to inc resistance
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post -hepatic htn ?
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Budd-Chairi syndrome
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cause of pre-sinusoidal htn ?
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S. mansoni
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cause of post-sinusoidal htn ?
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centri-lobular fibrosis
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how nitric oxide works in liver..
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Normally, increases in flow and subsequent shear stress lead to an increase in perfusion pressure, that in turn leads to a flow-dependent increase in NO production that serves to limit the increase in perfusion pressure.
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progession of cirrhosis
P= F x R |
inc reistance in portal flow
dec resistance in sphlanic *** or inc portal flow ---- can inc portal pressure and lead to VARICES*** |
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HYPERDYNAMIC CIRCULATORY STATE IN CIRRHOSIS
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In portal hypertension, splanchnic and systemic vasodilatation lead to a decrease in effective arterial blood volume that activates sodium-retaining neurohumoral systems that lead to plasma volume expansion and the hyperdynamic circulatory state.
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how does cirrhosis cause multisystemic illness ?
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****neurohormonal activation - leads to Na and water re-absorption
In addition to maintaining the portal hypertensive state and leading to the formation and growth of varices, the hyperdynamic circulatory state (HCS) plays an important role in the development and/or worsening of all other complications of cirrhosis by affecting the function of different systems and organs. The HCS results from systemic vasodilatation, sodium retention and blood volume expansion. |
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what effect does activation of RAA have on the liver ?
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sodium retention, an essential mechanism in the development of ascites
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hepatorenal syndrome.
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With further peripheral vasodilatation, there is renal vasoconstriction, the main pathogenic element in the development of the hepatorenal syndrome.
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hyperdynamic state on heart ?
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The hyperdynamic circulatory state will eventually lead to high output heart failure with decreased peripheral utilization of oxygen.
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vasodilation on the lungs ?
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Vasodilatation at the level of the pulmonary circulation will lead to arterial hypoxemia, the hallmark of the hepatopulmonary syndrome.
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recall that NO is going to cause vasodilation.. due to portal htn and shear stress .. implications on brain ?
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can lead to edema and hepatic encephalopathy
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portal htn , also leads to ..
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VARICES and variceal rupture
V are present in 50% of cirrhotic patients |
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what is required for varices to form ..
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12 mmHg
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dx of portal htn - safest and most reproducible method is measurement of the hepatic venous pressure gradient (HVPG)
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HVPG = WHVP - FHVP
The hepatic venous pressure gradient (HVPG) is obtained by subtracting the free hepatic venous pressure (FHVP) from the wedged hepatic venous pressure (WHVP): |
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analysis or pressures
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pre-sinusoidal portal htn -not as bad b/c pressure can be dissapated
sinusoidal htn - fibrotic , so, can't really dissapate pressure post-sinusoidal-also poor pressure disapation , and therefore ** WHVP-is equal to portal pressure |
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Post-hepatic htn ***
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WHVP and FHVP are both elevated *** so HVPG appears normal
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review
inc gradients ? |
sinusoidal htn
and post sinusoidal (both can't disspate pressure ) and both therefore have high wedge pressure note post hepatic htn has a high free FHVP , so gradient is normal |
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***predictors of variceal hemorrhage
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size, red signs , child B/C
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variceal rupture
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Rupture of a vessel occurs when the expanding force exceeds its maximal wall tension. The higher the tension, the greater the possibility of rupture.
Tension in the varix (T) is directly proportional to transmural pressure (difference between the intravariceal and the intraluminal esophageal pressure) and to variceal radius (r) and is inversely proportional to variceal wall thickness. A large varix has a large radius and a thin wall and therefore a larger tension and a greater propensity to rupture. |
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why would you give vasoconstrictors to tx portal htn - artery selective ?
venodilators ? |
inc splanchnic resistance so less flow into portal circulation
dec portal pressure |
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what does a TIPS surgical shunt accomplish ?
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dec resistance to portal flow
can also obliterate variceal |
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tx of varices
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if none - prevent .. non-selective beta -blockers did not prevent , repeat endoscopy in 2-3 years
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tx/prevention for varices-no hemorrage
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non-selective beta-blckers did work here
adding a nitrate did not help spironolactone also did not help isosorbide-di-nitrate made it worse |
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Variceal Band Ligation (VBL) vs. Beta-Blockers to prv. first hemorrage
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VBL slightly better
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medium large varices with no hemorrage
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non-selective beta-blockage
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nadolol ..
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can prevent growth of small varices
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variceal hemorrage
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control is and give ****Antibiotic prophylaxis
IV access and fluid resuscitation Do not overtransfuse (hemoglobin ~ 8 g/dL) Pharmacological therapy: terlipressin, somatostatin and analogues, vasopressin + nitroglycerin Endoscopic therapy: ligation, sclerotherapy Shunt therapy: TIPS, surgical shunt combo Drug / Endoscopic Therapy is More Effective Than Endoscopic Therapy Alone in Achieving Five-Day Hemostasis |
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***recurrent variceal hemorrhage
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TIPS
TIPS is indicated in patients who rebleed on combination endoscopic plus pharmacologic therapy |
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TIPS inc risk of ?
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encephalopathy
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recurrent hemorrage
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1. b blockers + ISMN or EVL
2) beta-blockers + EVL may be preferable 3) TIPS / shunt surgery |
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gastric varices
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Endoscopic cyanoacrylate injection:
90% control of bleeding TIPS: 90% control of bleeding |
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gastric varices tx ?
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Gastric varices that are continuous with esophageal varices and extend along the lesser curve (GOV1) should be treated in the same way as esophageal varices
In patients with isolated fundal varices (IGV1), splenic vein thrombosis should be investigated. If present, treatment consists of splenectomy***** |
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Hepatic Encephalopathy
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reversible
Mm: Ammonia-glutamine neurotoxicity hypothesis Amino-acid imbalance hypothesis Synergism hypothesis GABA hypothesis Benzodiazepine hypothesis |
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NH3
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may bypass the liver through collaterals with portal htn
--or through a shunt - hence the risk with TIPS |
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next affect from NH3 ?
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Upregulation of astrocytic peripheral
benzodiazepine receptors (PBR) **this stimulates neurosteroid production how ? steroids then modulate GABA |
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3 types of enceph
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A - for Acute liver failure - can lead to cerebral edema
B - for bypass C - for cirrhosis , leads to shunting, toxin |
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signs of cerebral edema *****
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Decerebrate posture
Profuse sweating Tachycardia Cardiac arrhythmias High fever Hyperventilation Tachypnea Intermittent hypertension |
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West Haven HE Staging System***know this
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Grade 0: No abnormality detected
Grade 1: Change in personality, trivial lack of awareness, shortened attention, arithmetic difficulty Grade 2: Lethargy, loss of orientation for time, monotone voice, inappropriate behavior, obvious personality change Grade 3: Somnolent, responsive to stimuli, gross disorientation severe confusion Grade 4a: Coma; responsive only to major stimuli Grade 4b: Coma; unresponsive to any stimuli |
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precipitants of hep enceph
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excess protein
GI bleeding sedatives TIPS diuretics |
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precipitants of hep enceph ..more
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sepsis , hypokalemia , high proten , dehydration , sedatives , TIPS , GI bleeding
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dont confuse HE with alcohol ******withdrawl
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with alcohol withdrawl , will see more sweating, and hallucination **** BOARDS
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Asterixis - is not specific for liver disease
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Hypokalemia
Hypomagnesemia Cheyne-Stokes respiration Recovery from anesthesia Bromide intoxication Glutethimide intoxication Carbon dioxide narcosis HE CHF COPD Uremia Hypoglycemia Hypoxia Tranquilizer and/or sedative overdose |
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Tx for HE
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Stop source of ammonia*
(lower protein intake ) Remove substrate from GI tract* (catharsis, enemas) Suppress intestinal bacterial flora* (neomycin/rifaximin) ****lactulose rid of NH3 in NH4 form |
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Therapies to Increase Nitrogen Elimination*******
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Lactulose: goal: gut acidification to decrease NH3 absorption
dose: 30-120 mg/dL (titrate to 2 – 3 BMs/day) toxicity: flatulence, diarrhea, hypovolemia, acidosis, hypernatremia, perianal decubiti Neomycin: goal: decontaminate bowel dose: 1-2 gm po qid toxicity: oto- and nephrotoxicity Flagyl: goal: decontaminate bowel dose: 250 mg tid, qid toxicity: peripheral neuropathy Rifaximin: goal: decontaminate bowel dose: 400 mg tid |
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Mechanism of Action of Lactulose
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Catharsis:
osmotic diarrhea induced Alters colonic metabolism: traps nitrogen in stool; promotes nitrogen incorporation into colonic bacteria Acidification: lowers pH and reduces NH3 absorption Fatty acid metabolism: lactulose promotes production of non-toxic short chain fatty acids Alteration in intestinal glutamine metabolism |
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pathogenesis of ascites
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Portal Hypertension
Baroceptor activation Neurohormonally mediated abnormalities in renal perfusion with resultant sodium retention |
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portal vein obstruction and ascites ***
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obstruction does not lead to ascites
***hepatic vein obstruction will |
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what test to order to visulaize ascites ?
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ultrasound
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Serum-Ascites Albumin Gradient
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SAAG = serum albumin – ascites albumin
> 1.1 = portal hypertension < 1.1 = non-portal hypertension |
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Budd-Chiari syndrome
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occlusion of IVC or hepatic veins , leads to congestive liver disease ascties
****associated with polycythemia vera, pregnancy , hepatocellular carcinoma |
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high serum ascites gradients are associated with ?
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liver and cardiac issues !!!
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low gradients are associated with?
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non cardiac and non liver
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new onser ascites
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have to do a bedside culture
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treatment for portal htn , with no ascites..
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consider salt retention ..
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uncomplicated ascites
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salt resitrict annd diuretics
large volume paracentesis |
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uncomplicated ascites means ..
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no infection , no renal dysfunction
spirolactone and furosamine |
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refractory ascites ...
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LVP and albumin
TIPS PVS ( peritone-venous shunts |
|
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complications of ascites
|
Infection – SBP
***Tense ascites – respiratory distress Abdominal wall hernias/rupture Pleural effusions Peripheral venous stasis |
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Spontaneous Bacterial Peritonitis
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E coli adult
strep pneumo in kids PMNs > 250 and/or culture positive ****374 GOljan have to culture to get PMN count, otherwise would miss this gradient btw serum and ascitie fluid albumin , if greater than 1.1 than liver |
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peritoneal fluid analysis
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greater than 1.1 is liver orign, less than is peritoneum
|
|
|
SBP dx and tx ******
|
Diagnosis: Paracentesis: PMN’s > 250 /cc and/or + culture
Treatment: Broad spectrum antibiotics: cefotaxime (2 gm IV g 8 hr) ± ampicillin x 5 days avoid nephrotoxic medications (i.e. gentamycin) IV albumin 1.5 g/kg body wt within 6 hrs of detection then 1.0 g/kg on day # 3 (mortality decreased from 29% to 10% with albumin use) *****avoid aminoglycosides |
|
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Mm for SBP
|
migration of bacteria through meseteric lymph nodes
burnm trauma , shock - inc risk |
|
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indications for antibiotics to prevent SBP
|
cirrotic patients with GI hemorrag -- give Norfloaxacin****
this med shown to reduce recurrance .. |
|
|
secondary bacterial peritonitis
|
Total protein > 1 g/dL
Glucose < 50 mg/dL LDH > the upper limit of NL for serum surgical - from perforated bowel or ulcer |
|
|
Hepato-renal syndrome
|
vasodilation in extra-renal circulation
related to excess blood that does not get to where it needs to ? |
|
|
criteria to dx hepatorenal syndrome
|
creatnine greater than 1.5
slide 88 , review ***there will be sodium and water retention |
|
|
tx for hepatorenal syndrome
|
give pressors and albumin combo
***Midodrine aqnd Octreotide |
|
|
hepatorenal syn managment
|
transplant
pressor + albumin |
|
|
ascites summary
|
late compl of cirrhosis
mobilize ascites **1st line treatment of patients with cirrhosis & ascites consists of sodium restriction (88 mmol/day or 2000 mg/day) & diuretics (oral spironolactone & furosemide), Fluid restriction is not necessary unless serum Na < 120 – 125 mmol/L, |
|
|
AIDS and the GI tract
in order |
Esophagus
Diseases of colon Small bowel disease Hepatobiliary system Pancreas Stomach |
|
|
most common GI complication in HIV-infected patients
|
Oral Candidiasis
**Absence of oral candidiasis does not rule out candidal esophagitis |
|
|
complications of oral candidiasis ?
|
Gastrointestinal hemorrhage
Perforation Fistulas into lung or mediastinum Secondary bacterial infections with sepsis Malnutrition-most common |
|
|
cand. tx
|
Clotrimazole topical)
Nystatin (topical ) Ketoconazole Fluconazole Amphotericin B |
|
|
Ketoconazole ****
|
hypo/achlorhydria-seen in AIDS
use of H2-receptor antagonists or PPIs accelerated ketoconazole metabolism when drug is taken with either isoniazid or rifampin. |
|
|
volcano ulcer on scope , with edema
|
herpes simplex
|
|
|
intense retrosternal pain
|
HSV
|
|
|
HSV complications
|
Hemorrhage
Bacterial or fungal superinfection Rare dissemination Stricture formation Malnutrition-common-swallowing hurts ***endoscopy is superior to radiology |
|
|
Symptoms include dysphagia, odynophagia, and retrosternal pain.
|
Almost exclusively seen in immunocompromised patients
|
|
|
Foscarnet
|
tx forCMV , but adverse*****
renal failure and hypocalcemia |
|
|
Isoporiasis
|
eosinophilia is common
bactrim is tx |
|
|
Microsporidia
|
Ubiquitous, spore forming, obligate intracellular parasite
Human infection is most commonly seen with Enterocytozoon bieneusi |
|
|
Cytomegalovirus
|
Occurs anywhere in GI tract
esophagus and colon are the most common CD4 counts always <150; typically < 50 cells/mm3 |
|
|
CMV symptoms
|
Tenesmus
Hematochezia Diarrhea Mass lesions in bowel Perforation |
|
|
MAC
|
systemic
small intest. acid fast organism gut lesion , looks like Whipple's |
|
|
anorectal manifestations of AIDS
|
HSV-proctitis , ulceration
|
|
|
Kaposi's sarcoma
|
gingiva, palate, stomach, intestine
|
|
|
Biliary Peliosis Hepatitis
|
Treatment with erythromycin or tetracycline effects clinical response in some patients.
|
|
|
biliary tract disease
|
CMV
Cryptoporidium Microsporidium any combination |
|
|
high yield nutrition 1
|
being overweight , can still be malnourished
Prealbumin Half life is 2-3 days |
|
|
Rule of Thumb
ideal body weight |
Women 5’: 100 lbs
Add 5 lbs for every inch above Men 5’: 106 lbs Add 6 lbs for every inch above |
|
|
BMI < 18.5
|
is Underweight for all adult age groups (>18)
|
|
|
BMI 24 to 29
|
Healthy wt for age (>65 year olds)
BMI 24 to 29 is a Healthy wt for age (>65 year olds) |
|
|
Mifflin-St Jeor Equations
|
For obese patients to figure out resting metabolic rate
|
|
|
Estimated Nutrition Requirements
|
25 – 30 cal/kg/day elderly, maintenance, mild stress factor
30 – 35 cal/kg/day young to middle age adults, moderate to severe stress factor 35 – 40 cal/kg/day young adults, severe stress factor, need for weight gain **dont overfeed on a ventilator |
|
|
trauma , nut requirements
|
1.2 – 1.5 g/kg mild to moderate stress & repletion
|
|
|
HDL
|
resorvior for apo c II
activates lipoprotein lipase and apo E |
|
|
cholesterol should be?
|
less than 200 mg/ day
one egg has 130 mg |
|
|
prob with sat fat
|
inc LDL
|
|
|
diet for htn ?
|
DASH
but be careful with kidney patients*** b/c dash High potassium, magnesium & calcium Consume 2-3 servings of low fat dairy 4-5 fruits 4-5 vegetables 1500 mg of sodium |
|
|
salt amount for CHf patient
|
Low sodium (2000 mg/day)
shot pass around was 2400 mg |
|
|
pancreatitis and nutrition...*****
|
Low fat diet for pancreatitis
Heart disease – low cholesterol ***Place feeding tube beyond ligiment of treitz |
|
|
phenothiazines
|
antidopaminergic
Act at D2 in CTZ ****** extra-pyramidal and Parkinsonian symptoms pyramidal = corticospainal tract extra-pyramidal- what nuclei = basal ganglia = motor **tardive dyskinesia - extra-pyramidal , from drugs with anti-dop |
|
|
tardive dyskinesia
|
involunatary facial movements
today , better meds for schitzo insufficient dopamine |
|
|
anticholinergics
|
dilating pupil blocks canal of schlem
|
|
|
H2 blockers
|
Bedtime dose- nocturnal acid secretion
Few side effects**** |
|
|
PPI
|
inhibits pump itself , not the three stimuli ( Gasrin , Ach , histamine )
|
|
|
Metoclopramide
|
Act at D2
Prokinetic agent- gastroparesis increases gastric emptying and small bowel peristalsis ADR- ******dystonic reactions (treat with Benadryl 25-50mg IV/PO) |
|
|
Corticosteroids
|
Decadron, SoluMedrol via IV/PO
Chemotherapy-induced N/V in combination with other agents Hyperglycemia, edema, hypertension, ***mood swings, insomnia, euphoria |
|
|
Emesis , mediated with 4 receptors
|
Muscarinic (M1)
Histaminergic (H1) Dopaminergic (D2) Serotoninergic (5-HT3) |
|
|
Omperazole (prilosec), esomeprazole- PO (nexium)
|
mirror images , PPI
|
|
|
Interferon alfa
|
Injection for hep C , have to take for 6-12 months
Hep B – less in duration |
|
|
pancreatitis
|
45 y.o. W/F h/o of heavy alcohol intake for 10 years multiple hosp. for nausea, vomiting, epigastric abd pain rad to the back.
Dx: ?? Now c/o same but also c/o wt. loss, oily stools that don’t flush, easy bruiseability . Lab confirms steatorrhea |
|
|
pancreatic enzymne replacement
|
develop exocrine problems first, befor endocrine problems
amylase lipase protease |
|
|
benzimidazole
|
starves worm
thus ***inhibiting the polymerization of tubulin and microtubule-dependent glucose uptake |
|
|
****albendazole (albenza)
|
FDA approved for Neurocysticercosis
glucose uptake, imobilizes Treatment of parenchymal neurocysticercosis caused by Taenia solium and cystic hydatid disease adverse: acute renal failure allergic rxn |
|
|
Hydratid Disease (Echinococcus granulosus)
|
human is end host
goats and dogs are intermediate cysts could get big, nd cause an obstruction -press on bv and nerves |
|
|
Neurocysticercosis ( most common parasytic infection of the brain)
|
leading cause of seizure disorder in developing world
CT - ring enhanced lesion ... parasitic infection pork tapeworm involved *****Taenia Solium |
|
|
Mebendazole (Vermox)*******
|
pinworm
-Selectively and irreversibly blocks glucose uptake and other nutrients in susceptible adult intestine-dwelling helminths autistic kid -- differnt hygieine practice adverse: angioedema, fever , dizziness |
|
|
hookworm
|
sets up camp in intestine
hook onto the bowel wall, and can get sig bleeding --- chronic blood loss and iron def passed by host , develop into free living form migrate to lungs eosinophilia ****** (invasive) need quite a few to cause this |
|
|
Ascaris lumbricoides
|
No attachment or penetration of the adult worms occurs.
200K eggs a day Treatment: ***Mebendazole and pyrantel pamoate |
|
|
Enterobius vermicularis (Pinworm)
|
fecal oral spread , peri-anal , pruitis
eggs can be vaible for a month ****scotch tape test Mebendazole |
|
|
Trichuris trichuria (Whipworm
|
barrel shaped egg
|
|
|
Thia-bend-azole (Mintezol)
|
Treatment of cutaneous larva migrans, visceral larva migrans, dracunculiasis, trichinosis, strongyloidiasis (not drug of choice), and mixed helminthic infections
Inhibits helminth-specific mitochondrial fumarate reductase |
|
|
Toxocara sp.: Visceral larva migrans
|
dx- serum antibody
def carrier- is a dog or cat |
|
|
Ancylostoma braziliense
(visceral and cutaneous) |
get infection through the skin
Thiabendazole. Deworming pet dogs and cats and avoiding barefoot travel in infested areas are both good preventative measures |
|
|
IVERMECTIN****
|
drug of choice for the treatment of Onchocerca volvulus and for strongyloidiasis
(river blindness) control in Africa |
|
|
Strongyloides stercoralis
|
***** eosinophilia
Eggs hatch into larvae in the intestines and are passed in the feces. Autoinfection is caused by rhabditiform larvae that mature without leaving the host and penetrate the intestinal wall to migrate to the lungs. Infection can persist for decades. Hyperinfection from an autoinfection immunocompromised by AIDS, T-cell deficiency, or malnutrition. |
|
|
IVERMECTIN
|
affects nerve and muscle cells
|
|
|
Onchocerca volvulus
|
black fly , river blindness
Microfilariae concentrate in the eyes elephantiasis - infects lymph drainage |
|
|
IVERMECTIN**********
|
also for Strongyloidiasi********
: Mazzotti reaction (with onchocerciasis / loiasis): |
|
|
Diethylcarbamazine**********
|
The drug of choice for lymphatic filariasis
potent against microfilarial --- paralyzes worm onyl available through CDC Mazzotti test *** get systemic reactions |
|
|
Wuchereria bancrofti:
|
need a lot of organism to cause a problem
|
|
|
Schistosomiasis
|
parasitic blood fluke - schistosomes
Praziquantel - very well tolerated -- can get ...Katayama fever is a systemic hypersensitivity reaction against the migrating parasites, which occurs between two to eight weeks after exposure Increases the cell permeability to calcium in schistosomes |
|
|
IVERMECTIN
|
ADVERSE REACTIONS SIGNIFICANT
Hypotension, mild ECG changes, orthostasis, peripheral and facial edema, transient tachycardia Dizziness, encephalopathy (rare; associated with loiasis), headache, hyperthermia, insomnia, seizure, somnolence, vertigo Pruritus, rash, ***Stevens-Johnson syndrome, urticaria, toxic epidermal necrolysis |
|
|
folic acid def amount
|
less than 3 grams / day
|
|
|
folate absorption
|
Folate is absorbed best as monofolylglutamate (the synthetic form of supplements), while the natural isoform of vitamin E (RRR-alpha-tocopherol) is more effective than synthetic forms
|
|
|
inadequate mineral status
|
increases with low consumption of fish or fortified milk, plus high intakes of phosphate from colas, meat, and processed cheese.
|
|
|
when is a low protein diet appropriate ?
|
hepatic encephalopathy
|
|
|
cancer and nutrition
|
inc calorie and protein needs
|
|
|
fiber and diverticulum
|
Diverticulitis low fiber
Diverticulosis high fiber (25 g or more |
|
|
Irritable bowel disease vs. irritable bowel syndrome
|
IBS -- low fiber
IBS --- can give hgh fiberr |
|
|
when not recieving adequate nutrition ..
shift of stored body fat to carbs |
inc insulin and dec , K, Mg , glucose , and PO4 ******
this is called refeeding syndrome ? |
|
|
dont mix herbs with ?
|
blood thinning agents
|
|
|
statins and what herbs dont mix ?
|
Red yeast rice
Echinacea Astragalus Licorice Alfalfa |
|
|
dont use ginseng if.....
|
you have breast cancer
|
|
|
diabetes and pressure ulcers not healing
|
need more protein
|
