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196 Cards in this Set

  • Front
  • Back
Alcoholic fatty liver
Give signs and symptoms
-History of several days of heavy drinking and/or long term drinking
-Anorexia
-Nausea
-Right upper quadrant discomfort
-Hepatomegaly
-May have tender liver
Signs and symptoms of alcoholic hepatitis
Signs and symptoms of hepatitis in association with heavy alcohol use
-Severe alcoholic hepatitis has very high mortality rate
severe alcoholic hepatitis also has anorexia, nausea, abdominal pain, impaired liver function with jaundice, bruising, encephalopathy
-+/- Ascites
-With or without neutrophilic leukocytosis
Alcoholic cirrhosis.
List signs and symptoms
Nausea
weight loss
usually complications such as
Portal hypertension
Variceal bleeding and/or ascites
Liver failure
May lead to hepatocellular carcinoma
Treatment of ascites
Salt restriction to reduce fluid retention
manage portal hypertension with beta blockers
spironolactone, furosemide
transjugular intrahepatic porta-systemic shunting
Treatment of hepatic encephalopathy
-Treat precipitating factors
decrease colonic production absorption of ammonia with lactulose
treat H. pylori
Discuss hepatitis A
-RNA virus
Past fecal oral contamination
-Almost universal in underdeveloped countries
-More severe with advancing age
-Does not persist as chronic infection
-More associated with poverty and crowding then injection
indications vaccination
High-risk occupations
Travelers
Homosexual man
Patients with chronic liver disease
Discuss Hepatitis B
Most prevalent chronic infectious viral disease in humans
really transmitted among intravenous drug users
Hepatitis B
Risk groups for
-Risk group = multiple sexual partners
-risk group = homosexual man
Risk group = Asians, Southern Europeans, med geraniums
risk group = indigenous people
risk group = health care workers
risk group = children infected parents
Risk group = IV drug use
Hepatitis B
prodrome symptoms
Transient serum sickness prodrome (polyarthralgia, fever, malaise, proteinuria)
Hepatitis B
symptoms of acute infection
Anorexia
Nausea
sometimes vomiting
jaundice
pale stools
dark urine
often subclinical
Hepatitis B
chronic disease
Converts to chronic hepatitis B in 5% of adults
Hepatitis B
Diagnoses of chronic hepatitis B
HBsAg process for more than 6 months
Hepatitis B
complications of chronic active hepatitis B
Chronic hepatitis
cirrhosis
hepatocellular carcinoma
Hepatitis B
treatment of active chronic hepatitis B
Only if active liver inflammation
pegylated interferon is 30% effective
Use 2 or more agents
Discuss hepatitis C
Strongly associated with injection of drugs
incidence of approximately 20% per year of IV drug use
Most IV drug users are infected
low sexual transmission
Hepatitis C
Risk factors
Contaminated drug injection equipment
blood transfusions prior to 1990
incarceration (drug use)
body piercing and tattoos
10% transferred from mother to baby

low risk
sharing toothbrushes, razors etc.
healthcare workers, needlesticks
birth or medical procedures
sexual activity
Use a snorting straws

No evidence of transmission to casual household contacts no evidence of transmission through breast milk
Hepatitis C
Primary infection
Usually subclinical.
Peak viremia usually in week 2 or 3.
Hepatitis C
Chronic infection
Chronic infection develops and three fourths of patient's with acute infection.
Liver damage results from immune damage to infected cells.
8% well-developed cirrhosis after 20 years
20% well-developed cirrhosis after 40 years
Hepatitis C
symptoms of chronic hepatitis C
Severity does not correlate with disease activity well.
Usually nonspecific, mild, intermittent.
Most common symptoms are fatigue, nausea, muscle aches, right upper quadrant pain, weight loss
hepatitis C
percentage of acute infections that develop persistent chronic infection
60-70%
hepatitis C
mechanism of liver injury
Hepatitis C cause liver damage predominantly by immune damage to affected liver cells
hepatitis C
percentage of people developing cirrhosis
8% of hepatitis C. patient will develop cirrhosis in 20 years
-20% will develop cirrhosis in 40 years
Hepatitis C
how to make the diagnosis
Enzyme immunoassay or hepatitis C, it is good but many false positives.
does not differentiate between current and resolved infections..
Positive hepatitis C RNA tests indicates active infection.
Hepatitis C.
How to determine if infection has resolved?
Hepatitis C RNA test negative.
And
Positive antibody tests suggests cleared infection
Hepatitis C.
Assessing severity of disease
Symptoms do not correlate with severity of liver disease.
Spider nevi common but nonspecific.
Plasma ALT is best indicator of active viral hepatitis but does not indicate severity.
Hepatitis C.
Effect of alcohol and disease
Alcohol consumption in the presence of chronic hepatitis C has added effect of liver inflammation and accelerates hepatic fibrosis.

Heavy alcohol use:
increases viral load
increase risk of progression to hepatocellular carcinoma
Hepatitis C.
Dietary guidelines
No dietary guidelines for hepatitis C.
However dietary treatment of diabetes and obesity can slow progression of hepatitis
Hepatitis C.
Indications for antiviral treatment
Name indication for treatment of active hepatitis isn't elevated ALT and (if performed) biopsy evidence of fibrosis
+16
24
Hepatitis C.
Goal of antiviral therapy
The goal of antiviral therapy and hepatitis C is a sustained virologic response evidenced by normal ALT and negative hepatitis C PCR at least 6 months after treatment
Hepatitis C.
Risk of cirrhosis during sustained urologic response
There is a very low risk of cirrhosis after 6 months of sustained virologic response with normal PCR normal ALT
Hepatitis C.
Duration of treatment.
Drugs used
Pegylated interferon and ribavirin are drugs of choice.
Genotype 2 or 3 is treated for 6 months.
Genotype is one, 4, 5, 6 or cirrhosis are treated for 12 months
Hepatitis C.
Treatment of patient's with positive hepatitis CRNA and normal transaminases.
This disease is mild. Can treat if patient really desires. Generally, mildly discouraged treatment until ALT is abnormal or signs of progressive liver disease
Hepatitis C.
Treatment of patients with ongoing substance abuse
NIH recommends against treating patients with ongoing substance abuse (except methadone or buprenorphine).
Hepatitis C.
Side effects of interferon
Interferon therapy.
Flulike symptoms in 4-6 hours of injection.
Also may have more persistent symptoms of
fatigue
mood alterations
moderate suppression of white cell count
moderate suppression of platelet count
skin rash
anorexia and weight loss
Dryness of mucous membranes
Hair loss

major side effects
severe depression
retinopathy
Interstitial fibrosis lung
thyroid disease
Hepatitis C.
At what rate does hepatitis C cirrhosis progressed to hepatocellular carcinoma?
Annual rate of 3-5%
List of treatment for small primary hepatocellular carcinomas?
Excision
Whatever the indications for liver transplantation in the presence of hepatitis C?
Major complications of their cirrhosis.
Life expectancy of one-2 years without transplantation.
What is a 3 year post transplantation survival rate after hepatitis C?
84% = 3 year survival rate.
Equal to survival of other patients with transplantation of liver
What is hepatitis D?
Delta agent isn't effective viral RNA particle they cannot replicate without co-infection with hepatitis B.
What is cocaine hepatitis?
Cocaine hepatitis is uncommon condition causing about 1% of hepatic failures.
Probably occurs as a result of heat shocklike features of cocaine toxicity.
Is both dose and time-dependent.
What is the mechanism of cocaine hepatitis injury?
Cocaine hepatitis injury most likely cause by ischemia from the vaso constrictive effects of cocaine and possibly toxic metabolites.
What is the effect of alcohol and cocaine taken together?
Ethel cocaine (coca ethylene) is produced.
Has similar effects as cocaine
Has a little longer half-life, therefore accumulates at a higher dose.
Has lower LD 50
Can ecstasy produce hepatic injury?
Ecstasy and MDMA rarely cause hepatic injury.

When it occurs it is probably due to hypothermia and volume depletion at rave parties
What is the most common toxic material designed for oral use but injected?
Talc
accumulation causes damage at several sites, especially lung and liver
What is the pathogenesis of injected talc?
Talc is strongly fibrogenic in the long and leads to pulmonary granulomatous disease with progressive or fatal outcome.
Talc in liver is inconsequential
What is effects of opioids on the liver?
No hepatotoxicity from pure preparations of opiate agonists.
Opioid antagonist such as naltrexone can cause minor elevation of liver enzymes, but rarely serious.
What are the possible effects of anabolic steroids?
Cholestasis.
Toxic hepatitis.
Hepatic adenomas.
Hepatic carcinomas
hepatotoxicity from contaminants
Why is GFR important in drug treatment?
GFR can be reduced because of nephrotoxicity.
GFR is used to adjust medication dosages.
List renal problems associated with opiate use.
HIV nephropathy.
Hepatitis C associated glomerulonephropathy is.
Hepatitis B associated polyarteritis nodosa.
Bacterial endocarditis and acute glomerulonephritis.
Subcutaneous injection amyloidosis.
Nontraumatic rhabdomyolysis and acute renal failure.
heroin nephropathy
List renal problems associated with cocaine usage.
Cocaine usage can cause:
Rhabdomyolysis and acute renal failure.
Accelerated hypertension and renal failure.
HIV nephropathy.
Hypertensive nephrosclerosis.
Renal infarction.
Thrombotic microangiopathy and renal failure.
List renal problems associated with alcohol consumption
Alcohol consumption is associated with:
Hepatorenal syndrome.
Rhabdomyolysis and acute renal failure.
Increased incidence and severity of postinfectious glomerulonephritis.
Electrolyte disorders
Define
nephrotic syndrome
Nephrotic syndrome characterized by
heavy proteinuria (>3.5 g per day).
Hypoalbuminemia.
Hyperlipidemia.
Lipid area.
Edema.

Not all characteristics must be present to diagnose
State differences between nephritic and nephrotic syndromes
Both have:
Proteinuria greater than 3.5 g per 1.73 m² body surface.
Hypoalbuminemia.
Hyperlipidemia.
Edema.
Hypertension.
Renal insufficiency.

Nephritic syndrome also has hematuria due to larger pore size.
What is the most common presentation of renal disease with hepatitis C?
Renal disease in the presence of the hepatitis C. most often presents with:
-Nephritic and nephrotic syndrome.
Urine contained large amounts of protein, red blood cells, red blood cell casts
Heroin nephropathy.
Discuss.
Heroin nephropathy is a secondary cause of focal and segmental glomerulonephritis,
often associated with hypertension
Often associated with slow progression to ESRD
rarely encountered
The frequency of coexistence of hepatitis C and HIV drug users is__?
78% of HIV drug users have hepatitis C.
What is the treatment of acute hypertension in connection with cocaine use?
Steroids
Drugs of abuse associated with rhabdomyolysis
Phencyclidine.
Methamphetamines.
MDMA.
Cocaine.
Heroin.
Alcohol.
Discuss
hepatorenal syndrome.
Hepatorenal syndrome is a result of chronic alcohol ingestion producing liver damage.
Is a state of profound renal vasoconstriction and splanchnic basal dilatation associated with severe liver function impairment.
Often with hypertension and ascites.
Diagnosis and prognosis of
hepatorenal syndrome
Diagnosis of hepatorenal syndrome is a diagnosis of exclusion.
Must have trial of volume replacement with salt poor albumin (NOT saline). Removal of any potentially nephrotoxic agents. No improvement of oliguric acute renal failure makes diagnosis of hepatorenal syndrome probable.
Prognosis is almost always fatal unless successful liver transplant
What is
Ecstasy?
Ecstasy =
MDMA =
methylenedioxymethamphetamine.
Effects of MDMA at rave party
MDMA can lead to
agitation
high fever
hyperventilation
impaired sensorium

increase insensible fluid losses leading to dehydration, hypernatremia and fluid depletion

this results in hypotension, shock, brain damage, rhabdomyolysis and renal failure
Major targets of alcohol and other drug toxicity
Liver is major target for toxicity
Hepatic cirrhosis is___leading cause of death in. US

___Most common cause of death in middle-age American man
12th

fifth
Number of dead Puryear from hepatic cirrhosis
28,000
Most common causes for liver transplantation
Hepatitis C
alcoholic cirrhosis
Amount of alcohol needed to produce fatty liver.
Fatty liver can occur after a single heavy drinking episode

usually needs 10 years of alcohol consumption at 100 g per day to develop alcoholic liver disease
How much alcohol is in a standard drink
Standard drink contains 14 g of alcohol
How much alcohol as needed to develop hepatic cirrhosis?
Hepatic cirrhosis usually requires long-term alcohol consumption a 40 g per day for men or 20 g per day for women.

Very heavy drinkers have only 50% chance of developing cirrhosis.
Risk factors for alcoholic liver disease
Women require only half the amount of alcohol as men to develop alcoholic liver disease.

Genetics can produce threefold susceptibility to liver disease.

Nonalcoholic fatty disease progresses more common with obesity.

Obesity increases risk of alcoholic liver disease
Chronic alcohol consumption increases hepatotoxicity of what classes of drugs?
Chronic alcohol consumptions increases hepatotoxicity of:
Acetaminophen.
Industrial solvents.
Anesthetic gases.
Illicit drugs
What is the cause of alcoholic liver damage?
Alcoholic liver damage was previously thought to be due to poor nutrition. Today, thought to be direct result of alcohol ingestion even with adequate nutrition
How does chronic alcohol consumptions increases hepatotoxicity?
Alcohol induces CP Y2 E1 which also metabolizes many other things
Alcoholic fatty liver
history, signs and symptoms
alcoholic fatty liver occurs.
After heavy or long term drinking, even for several days

anorexia
Nausea
Right upper quadrant discomfort
enlarged liver
plus/minus liver tenderness
Alcoholic hepatitis
signs and symptoms
Alcoholic hepatitis produces
signs and symptoms of hepatitis in association with heavy drinking.
Anorexia
Nausea
Abdominal pain
impaired liver function
Jaundice
Bruising.
Encephalopathy
Fever and/or leukocytosis
+/- Ascites

Rare a high mortality
Alcoholic cirrhosis
Signs and symptoms
Alcoholic cirrhosis
Nausea
Weight loss
Portal hypertension
Variceal bleeding and/or ascites
Liver failure
May lead to hepatocellular carcinoma
Alcoholic liver disease
make diagnosis
Diagnosis of alcoholic liver disease
liver function tests
Gamma GT almost always raised
Transaminases usually elevated

if transaminases greater than 500, suggest additional disorders such as acetaminophen ingestion viral hepatitis or liver ischemia
Significance of AST/ALT ratio
If ALT >AST,
suspect chronic hepatitis C,
acetaminophen ingestion
Other liver injury

It AST >ALT (usually 2:1)
suspect alcoholic liver disease
Alcoholic hepatitis
described pathogenesis
Pathogenesis of alcoholic hepatitis
neither predictable nor preventable
Multifactorial
factors include host, toxin, metabolic

ethanol metabolizes to cetyl aldehyde via ADH and a.l. pH enzymes.
Acetyl aldehyde affects many aspects of normal so function

Second pathway and chronic alcoholism involves cytochrome P4 52 E1.
Alcoholic liver disease
Treatment
Treat alcoholic liver disease mainly by avoiding further alcohol.
If 6 weeks abstinence resolves elevated liver function tests, may return to drinking had low-level if able to control
Alcoholic liver disease
what is apparent half-life of gamma GT?
Gamma GT has an apparent half-life of 26 days. Of failure to drop suggest coexisting disease
Pharmacotherapies for alcohol dependence
baclofen
Disulfiram
Acamprosate
Naltrexone
Cortisone
Pharmacotherapies for alcohol dependence:
baclofen has shown promise

Disulfiram contraindicated in advanced liver disease

Acamprosate contraindicated in severe decompensated liver disease

Naltrexone associated with dose-dependent hepatotoxiciities.

Cortisone prednisone 40 mg per day x28 days sometimes works
Effect of alcohol on myocardial contractility
alcohol depresses cardiac contractility
What are metabolites of alcohol

What are their pharmacologic effects?
The metabolites of alcohol are
acetyl aldehyde
acetate.

Acetyl aldehyde and acetate at adrenergic and vasodilatory effects.
Why does cardiac output increased with alcohol and healthy patient's?
Alcohol increases heart rate and reduces peripheral resistance.
However, left ventricular ejection fraction is reduced
alcohol increases skin and splanchnic blood flow but reduce his pancreatic flow
What is effect of alcohol on ischemic myocardium?
In ischemic myocardium, alcohol cannot increase fail a so dilation because it is already maximally dilated.
Dilatation of is adjacent tissue vessels produces a "coronary steal" which increases myocardial damage

Alcohol may mask angina.

Alcohol may precipitate coronary spasms
Alcoholic heart disease.
List effects of alcohol
Excessive alcohol can produce
hypocontractile heart.
Reduced cardiac output.
Increased systemic vascular resistance in alcohol cardiomyopathy.
Hyperdynamic heart.
Four-chamber dilatation
cardiomegaly.
Interstitial and perivascular fibrosis.
Alcoholic cardiomyopathy
Described cause and effects
Alcoholic cardiomyopathy is a clinically distinct disorder in alcoholics without nutritional deficiency.
Dilated hypocontractile heart.
Probably due to toxic effect of acetyl aldehyde.
Requires prolonged excessive use of alcohol for greater than 10 years.
90% of patients are black.
What is holiday heart?
Excessive alcohol, especially binge drinking produces cardiac arrhythmias.
Atrial fibrillation most common.
Therefore always look for alcohol in the presence of cardiac arrhythmias.
What is thought to be the cause of sudden cardiac death in alcoholics?
Sudden cardiac death in alcoholics is thought to be due to arrhythmias most likely produced by alcohol withdrawal symptoms.
Nicotine
effect on heart rate and blood pressure
on skin
Nicotine increases heart rate and blood pressure for at least 30 minutes

reduces blood flow to skin
Nicotine
effect on coronary arteries
On hemoglobin.
On platelet aggregation and blood viscosity.
On HCL
in conjunction with women taking oral contraceptives
Effects of nicotine.
Coronary artery spasm.
Increasing carboxyhemoglobin decrease his oxygen delivery.
Induces platelet aggregation and blood viscosity.
Lowers HDL
Coronary risk reduction by stopping smoking
Nicotine replacement does not cause heart disease.

2 years of nicotine abstinence reduces coronary risk by 50%.

20 years nicotine abstinence reduces coronary risk to that of nonsmokers
Cannabis
effects on circulatory system and heart
Cannabis, regardless of method abuse.
Increases heart rate up to 50%.
May increase, decrease I have no effect on blood pressure.
Causes basal dilatation.
Cardiac output increases because of increased heart rate and basal dilatation.
Increases carboxyhemoglobin.
5 times more likely to have AMI within one hour of smoking cannabis.
Opioids
effects on cardiovascular system
Opioids.
Lower blood pressure.
Reduce heart rate.
Have favorable effect on myocardial ischemia.
what are the four neurotransmitter systems within the brainstem reticular formation?
serotonin, acetylcholine, dopamine, noradrenaline
Cocaine
treatment of cocaine-induced vasoconstriction
A. What not to use
Cocaine induced vasoconstriction of coronary arteries is enhanced by a beta adrenergic blocker propanolol!
Cocaine
treatment of cocaine-induced vasoconstriction
B. What to use
Coronary vaso constrictive action of cocaine is attenuated by alpha adrenergic blocker phentolamine
Cocaine
acute coronary syndrome
Acute coronary syndrome with cocaine.
Occurs in adolescence in young people.
Occurs in both occasional and habitual cocaine users.
First hour after cocaine use as greatest risk.
Coronary thrombosis is usual cause
Cocaine
Acute coronary syndrome
Treatment
Treatment of acute coronary syndrome produced by cocaine.
Nitroglycerin both sublingual IV.
Prevent seizures with benzodiazepines. May need angiography and thrombolysis.
Morphine can attenuate cocaine-induced vasospasm therefore useful for continuing chest pains

Do not give beta blockers until coronary patency established
Cocaine.
Effects of chronic cocaine usage on heart
Chronic cocaine usage.
Increases atherosclerosis
increases myocardial injury
Increases vascular complications related to hypertension.
Part of damage to his from repeated elevations of blood pressure.
Can also cause sudden cardiac death by producing arrhythmias
Amphetamines
list significant amphetamines of abuse
Amphetamines and related compounds are.
T., L., amphetamine.
Methylphenidate.
Methamphetamine.
MDMA
Amphetamines. Effects on cardiovascular system
Amphetamines effect on cardiovascular system.
Dose-dependent elevation of blood pressure and heart rate
Phencyclidine and lysergic acid diethylamide.
Effects on cardiovascular system
Phencyclidine (PCP) and lysergic acid diethylamide.
Increased heart rate
Anabolic steroids
side effects
Anabolic steroids (mainly testosterone at its congeners) use in 100-1000 times therapeutic doses can produce.
Marked cardiac hypertrophy.
Acute myocardial infarction even with patent coronary arteries
stroke
Physical signs of addiction
skin
HEENT
cardiovascular
Physical signs of addiction
skin
Wrinkles from tobacco
Scars from injection
Palmar erythema of alcoholism


HEENT
Mouth cancer
Tooth staining from tobacco
Extreme tooth decay from methamphetamine (causes xerostomia and bruxism)

cardiovascular
murmurs from valvular disease
Physical signs of addiction
Abdomen
breasts
Male genitourinary
Female genitourinary
Lymph nodes
Physical signs of addiction
Abdomen
Especially liver

breasts
Gynecomastia

Male genitourinary
Prostatism
Colon and breast cancer increased with alcoholism

Female genitourinary
STDs

Lymph nodes
supraclavicular suggest lung cancer
axillary and inguinal nodes
Best lab test for nutritional status
The best test for nutritional status is
serum pre-albumin
Treatment of heroin addict in the hospital
Give 10-20 mg of methadone and repeat in 2 hours.
Repeat methadone daily.

If history of prior withdrawal give diazepam 10-20 mg orally or 5-10 parenterally
Treatment of pain in opiate addict
Opioid addicts must have higher doses to control pain.
Control the pain then put on schedule.
Do not use p.r.n. dosing
Alcohol withdrawal.
How long after last drink before DTs start?
DTs we'll begin in 6-48 hours after last drink
what are the sympathetic splanchnic nerves to the GIT?
thoracic, lumbar
Alcohol withdrawal. What are symptoms of delirium tremens?
The symptoms of delirium tremens are:
Tremor.
Moist warm skin.
Hypertension (treat with clonidine)
Agitation (treat with haloperidol).
Tachycardia (treat with benzodiazepines and maybe beta blockers).
Seizures (treat with benzodiazepine, NOT DILANTIN!
which structures are suspended by mesentery?
jejunum, ileum
Cause and treatment of Wernicke-Korsakoff syndrome
Wernicke-Korsakoff syndrome Caused by thiamine deficiency.

Give 100 mg thiamine IM before giving glucose
Korsakoff syndrome
Symptoms
Main symptom of Korsakoff syndrome is confabulation
Alcoholic cerebellar dysfunction.
Symptoms
Alcoholic cerebral dysfunction
Ataxia and incoordination
Often irreversible
Alcoholic peripheral neuropathy symptoms
Symptoms of alcoholic peripheral neuropathy.
Burning pain
numbness in stocking glove distribution
Symptoms of alcoholic hepatitis
Alcoholic hepatitis symptoms.
Fever.
Leukocytosis.
Right upper quadrant pain and tenderness.
Elevation of AST greater than ALT.
Complications of hepatic cirrhosis
Complications of hepatic cirrhosis are.
Hypoalbuminemia.
Coagulopathy.
Hyperbilirubinemia.
Hepatic encephalopathy.
Esophageal or gastric variceal bleeding.
Ascites.
Spontaneous bacterial peritonitis.
Volume overload and edema.
Hepatorenal syndrome
Was a five-year prognosis for cirrhosis if continues drinking
50%
Alcoholism
hematologic consequences
Iron deficiency from gastrointestinal hemorrhage, Mallory-Weiss tears

pancytopenia.

Folate deficiency producing megaloblastic anemia
Alcoholism, cardiovascular consequences
Cardiovascular consequences of alcoholism.
Hypertension, especially during withdrawal.
Alcoholic cardiomyopathy and congestive heart failure.
Effects of alcoholism on EKG
EKG shows diffuse hypokinesis and four-chamber dilatation
Effects of alcoholism on esophagus
Alcoholism effects of esophagus.
Gastroesophageal reflux.
Characteristic lesions of alcoholic gastritis
Characteristic lesions of alcoholic gastritis her subepithelial hemorrhages and epithelial erosions.
Predisposing factors to pancreatitis are...
Heavy alcohol consumption.
Gallstones
these account for 75% of pancreatitis
What percentage of heavy drinkers develop pancreatitis?
5% heavy drinkers develop pancreatitis
Factors leading to tissue injury in pancreatitis are...
Oxidative stress.
Autodigestion
Mechanism of alcohol causing pancreatitis.
Alcohol contracts the sphincter of Oddi and inhibits pancreatic secretion.
Results in the cascade of autodigestion
Diagnoses of pancreatitis
Attack of severe abdominal pain and tenderness.
Elevation of serum amylase more than 3 times normal.
Imaging studies suggestive of inflammation
Treatment of pancreatitis
Bedrest.
Analgesics.
Intravenous fluids.
Fasting
Chronic pancreatitis.
Cause.
Clinical features
Principal cause of chronic pancreatitis is excessive consumption of alcohol (75% of cases).

Clinical features
pain his chief problem.
Upper abdominal pain that may radiate to the back.
Pain increases with meals.
Anorexia and weight loss.
Can lead to diabetes and steatorrhea.
The most common cause of pancreatitis and children is...
Most common cause of pancreatitis and children is

cystic fibrosis
Mechanism of diarrhea in acute and chronic alcoholism
Diarrhea in alcoholics occurs from
altered motility.
Altered permeability.
Nutritional disorder.
Small intestinal mucosal injury
Treatment of opiate-induced constipation
Increase fluid intake
fiber supplementation
lactulose
Body packing
Ingestion of condoms or other bags filled with cocaine or other drugs.
Absorption can occur without rupture of the bag.
Takes 3-6 days to clear GI tract.
Give dilute contrast media to assist visualization
Effective cocaine and amphetamines on gut
Cocaine mainly causes ischemic injury of the gut producing
intestinal perforation
Infarction
Ischemic colitis
Drugs associated with pulmonary complications.
Central nervous system stimulants
Drugs associated with pulmonary complications.
Central nervous system
nicotine.
Cocaine and crack.
Amphetamines.
MDMA.
Methylphenidate.
Caffeine
Drugs associated with pulmonary complications.
Central nervous system depressants
Drugs associated with pulmonary complications.

Central nervous system depressants.
Alcohol.
Barbiturates.
Benzodiazepines.
GHB (gamma hydroxyl butyrate).
Opiates
Drugs associated with pulmonary complications.
Central nervous system
Drugs associated with pulmonary complications.
Central nervous system
Volatile substances
Aromatic hydrocarbons
Nitrous oxide.
Nitrites.
Refrigerants
Where is automaticity of respiration controlled in the brain?
Automaticity of respiration is controlled by the medulla oblongata.
But modulated by reticular activating system, cerebral cortex, and peripheral sensors
Where is hypoxic drive regulated?
Hypoxic drive comes from the carotid body. When stimulated it causes hypotension and bradycardia
Described respiratory depression symptoms
Patients with respiratory depression are:.
Somnolent or postictal.
Rapid and shallow respirations.
Limited ability to cough.
What are the medical complications of respiratory depression?
Medical complications of respiratory depression are.
Atelectasis.
Hypoxemia.
Hypoventilation.
Inability to clear secretions.
Broncho-aspiration.
What is the management of respiratory depression?
Management of respiratory depression.
Look for history of drug abuse.
Look for positive toxicology screen.
electrocardiogram.
Blood gas.
Chest x-ray

treat with.
Thiamine.
Glucose.
Naloxone
Discuss
atelectasis.
Causes, pathophysiology, treatment
Atelectasis

In respiratory depression, shallow respirations may not exceed critical closing volume and result in airway collapse.
Ineffective cough and aspirated secretions, loss of surfactants lead to atelectasis.
Unventilated areas are still perfused causing shunting and therefore hypoxemia.

Treat with.
incentive spirometry,
respiratory suctioning.
Chest physiotherapy.
Supplementary oxygen. Possible bronchoscopy
Discuss.
Aspiration pneumonitis
Aspiration Pneumonitis.
Usually caused by aspiration of oral secretions or gastric contents.
Usually only chemical pneumonitis but can lead to noncardiogenic pulmonary edema and respiratory failure with or without bacterial superinfection.
Infiltrates develop within hours to days.
Do not treat prophylactically with antibiotics
What are the causes of respiratory infections with chronic use of drugs?
Chronic addictive drug users her susceptible to a variety of infections.
Many drugs affect leukocyte function.
Malnutrition.
Immune d deficiency occurs.
Septic injections.
May need cortisone for COPD plus producing immunosuppression.
What are contaminants of illegal injected drugs ?
Common contaminants of illegal injected drugs are.
Mannitol.
Cellulose.
Talc.
. Sugars.
Phenobarbital.
Methyl quinolone.
Caffeine.
Procaine
Discuss.
Talc Granulomatosis
Talc granulomatosis.
= Magnesium silicate.
Widely use is a filler in oral medications.
Can be added as a contaminate of injected drugs.
Produces a syndrome similar to sarcoidosis. Insidious onset of granulomatous interstitial fibrosis.

Symptoms are.
Dyspnea.
Dyspnea with exertion.
Cough.
Talc retinopathy in half of the patient's.
Chest x-ray shows micral nodular interstitial capacity in some patients. CT me revealed diffuse groundglass opacity and confluent perihilar masses.
PFT shows low diffusion capacity as first abnormality.
Lung biopsy often needed to establish diagnosis.
Sometimes improve with steroids
Discuss
Pulmonary Hypertension
Pulmonary Hypertension
multiple mechanisms.
Chronic hypoxemia related to interstitial lung disease and vasoconstriction.
Pulmonary arterial thrombosis at sites of foreign body granulomatosis.
Primary pulmonary hypertension can occur as a result of HIV infection.

Common presentations involve dyspnea on exertion.
Physical exam an EKG often normal or right ventricular enlargement.
What is the most common pulmonary complication of intravenous heroin users?
Septic thromboemboli is the most common pulmonary complication of intravenous heroin use.
What are the advantages of inhaling drugs?
Inhalation route of drug administration has the following advantages.
Ease of administration.
Rapid onset of action.
Dose minimalization.
Avoidance of intravenous injection.
Avoidance of hepatic first pass effect.
Discuss
Barotrauma with Inhalation of Drugs
Barotrauma can occur with inhalation of cocaine, heroine, 3, 4 methylenedioxymethamphetamine. Marijuana. Tobacco and volatile substances.
Produced by extreme breath-holding against closed glottis e.g. prolonged Valsalva maneuver, to increase drugs effect
Alveolar bleb rupture.
Dissection of air along peribronchial pass into mediastinum, pleural cavities, skin and retropharyngeal space

some users exhale smoke forcibly into another users mouth, sometimes producing barotrauma
Components of tobacco causing lung cancer
Cigarette tardus associated with high rates of
lung cancer,
emphysema,
bronchitis,
airway reactivity
What are the adverse effects of environmental tobacco smoke?
Adverse effects of environmental tobacco smoke in children are.
Lower respiratory illness.
Chronic respiratory symptoms.
And middle ear disease.
Reduced lung function.
Asthma.
And wheezing in early childhood.

Adults.
Increase risk of lung cancer.
Cardiovascular disease.
Acute respiratory symptoms of illness
Criteria for diagnosis of
Chronic Bronchitis
Criteria for diagnosis of chronic bronchitis.
Sputum production for at least 3 months and 2 consecutive years in the absence of other causes of chronic cough.
Nonspecific airway changes, but usually.
Mucous gland hypertrophy of intermediate size airways.
Overproduction of the mucus may overwhelm mucociliary escalator
Described
Pulmonary Emphysema
Pulmonary emphysema develops with irreversible a large dose of airspaces distal to the terminal bronchial, with destruction of the alveolar wall
Components of tobacco causing lung cancer
Cigarette tardus associated with high rates of
lung cancer,
emphysema,
bronchitis,
airway reactivity
What are the adverse effects of environmental tobacco smoke?
Adverse effects of environmental tobacco smoke in children are.
Lower respiratory illness.
Chronic respiratory symptoms.
And middle ear disease.
Reduced lung function.
Asthma.
And wheezing in early childhood.

Adults.
Increase risk of lung cancer.
Cardiovascular disease.
Acute respiratory symptoms of illness
Criteria for diagnosis of
Chronic Bronchitis
Criteria for diagnosis of chronic bronchitis.
Sputum production for at least 3 months and 2 consecutive years in the absence of other causes of chronic cough.
Nonspecific airway changes, but usually.
Mucous gland hypertrophy of intermediate size airways.
Overproduction of the mucus may overwhelm mucociliary escalator
Described
Pulmonary Emphysema
Pulmonary emphysema develops with irreversible a large dose of airspaces distal to the terminal bronchial, with destruction of the alveolar wall
Discuss
Blue Bloater
•Chronic bronchitis (blue bloaters)
◦Patients may be obese.
◦Frequent cough and expectoration are typical.
◦Use of accessory muscles of respiration is common.
◦Coarse rhonchi and wheezing may be heard on auscultation.
◦Patients may have signs of right heart failure (ie, cor pulmonale), such as edema and cyanosis.
◦Because they share many of the same physical signs, COPD may be difficult to distinguish from congestive heart failure (CHF). One crude bedside test for distinguishing COPD from CHF is peak expiratory flow. If patients blow 150-200 mL or less, they are probably having a COPD exacerbation; higher flows indicate a probable CHF exacerbation.
Discuss
Pink Puffer
•Emphysema (pink puffers)
◦Patients may be very thin with a barrel chest.
◦They typically have little or no cough or expectoration.
◦Breathing may be assisted by pursed lips and use of accessory respiratory muscles; they may adopt the tripod sitting position.
◦The chest may be hyperresonant, and wheezing may be heard; heart sounds are very distant.
◦Overall appearance is more like classic COPD exacerbation.
Cause of pulmonary hypertension and cor pulmonale
Pulmonary hypertension and cor pulmonale.
Caused by chronic hypoxic vasoconstriction the pulmonary vasculature leading to pulmonary arterial hypertension and right heart strain
Symptoms of pulmonary hypertension and cor pulmonale
Symptoms of pulmonary hypertension and cor pulmonale.
Tachycardia.
Prominent neck veins are.
Tricuspid insufficiency murmur.
Right ventricular third heart sound.
Hepatojugular reflex.
Peripheral edema
What are the products of marijuana combustion?
Marijuana combustion produces the same chemicals as cigarette smoke except that it does not contain nicotine. It also contains THC and other cannabinoids.
Compare marijuana and tobacco smoke.
Marijuana smoke has 3 times as much tar cigarettes. Produces 5 times the carboxyhemoglobin level is cigarettes.
Marijuana does not contain nicotine.
Marijuana is just as dangerous as cigarettes except that it produces less emphysema or accelerated decline of FEV1
What effects does cocaine have on neurotransmitters?
Cocaine blocks
norepinephrine reuptake.
Serotonin reuptake

Cocaine causes release of
Norepinephrine
Serotonin!
Dopamine
How much cocaine actually reaches the lung when cocaine is inhaled
About one third of inhaled cocaine reaches along
Discuss speedballing
Speedballing = combining cocaine with heroin or morphine to attenuate the sudden decrease of euphoria
Discuss freebasing
Freebasing = process of using volatile solvents to convert cocaine from assault the base and remove adulterants.
Freebase product is highly potent with rapid onset of action and more likely to produce side effects
What are the physiologic effects of cocaine?
Cocaine produces
marked vasoconstriction
reduced diffusion capacity
damage to the alveolar capillary membrane
alveolar hemorrhage
noncardiogenic pulmonary edema
Reduction and immunologic capacity
inhibits function of natural killer cells.
What are upper airway complications of cocaine use?
Cocaine may produce the following and upper airways.
Nasal septal perforation because of the vasoconstrictive effect.
Sinusitis, epiglottitis.
Vasculitis
Discuss pulmonary edema with cocaine
Cocaine reproduce cardiogenic pulmonary edema or noncardiogenic pulmonary edema.
Discuss "Crack Lung"
Crack lung occurs 1-48 hours after heavy cocaine smoking.
Consists of chest pain, cough, hemoptysis, dyspnea, bronchospasm, pruritus, fever, diffuse alveolar infiltrates without effusions, pulmonary and systemic eosinophilia.
What are the general effects of amphetamines? On the respiratory system
Amphetamines. Increased sympathetic stimulation.
By causing release of biogenic amines.
By inhibiting reuptake of biogenic amines.

Effects of amphetamine are primarily cardiovascular and neurologic.
Also cause some bronchodilatation
What is caffeine?
Caffeiine is a phosphodiesterase that raises intracellular cyclic adenosine monophosphate
Where the effects of caffeine on the respiratory system?
Caffeine produces smooth muscle relaxation therefore mild bronchodilator are properties
What are the effects of opioids on the respiratory system?
Opioids affect the respiratory system mostly at the alveolar walls, but also tracheal and bronchial smooth muscle.

Most dramatic effect of opioids and respiratory system is indirect by acting on the CNS to reduced responsiveness to carbon dioxide and depress respiratory automaticity and cough.
How long does respiratory depression last with opioids?
Maximal respiratory depression occurs within 10 minutes after IV dose of opioid oral up to 90 minutes after subcutaneous or IM dose.

Respiratory depression lasts 4-5 hours
Where the principal respiratory complications of opioid overdose?
The complications of opioid overdose are pulmonary edema and respiratory failure
Discuss pulmonary edema and heroin
Opioid overdose, especially heroin is a common cause of pulmonary edema in younger patients. 50% of overdose patient's present with pulmonary edema.

20% of this group will die
Further respiratory effects of alcohol?
Alcohol intoxication can produce respiratory depression as well as.
Atelectasis.
Hypoxemia.
Respiratory acidosis.
Aspiration.
Adult respiratory syndrome.
Respiratory failure
What is the mechanism metabolic acidosis and respiratory alkalosis with alcohol ingestion?
Alcohol ingestion can produce alcoholic ketoacidosis.
Which produces metabolic acidosis.
Which stimulates compensatory respiratory alkalosis.
Described hepatopulmonary syndrome
Hepatopulmonary syndrome occurs in 8 days 15% of patients with cirrhosis.
Triad of.
Liver dysfunction.
Intrapulmonary or other vascular dilatation.
Arterial hypoxemia
Discuss effects of sedative hypnotics on respiratory system
Sedative hypnotic drugs. Her significant respiratory depressants when abuse or mix with alcohol or opiates
What is the most common cause of barbiturate overdose?
Most common cause of barbiturate overdose is accidental or intentional oral ingestion by a seizure patient or family member.
What is the usual cause of death and sedative hypnotic overdose?
Most sedative hypnotic overdose tests occur as a result of adult respiratory distress syndrome secondary to either a chemical aspiration pneumonitis or bacterial pneumonia
What are the symptoms of sedative hypnotic withdrawal?
Sedative hypnotic withdrawal symptoms are.
Tachypnea (most common)..
Anxiety.
Tremor.
Headache.
Diaphoresis.
Difficulty concentrating.
Insomnia.
Hallucinations.
Fatigue

withdrawal occurs to-5 days after last dose
What the symptoms are barbiturate withdrawal?
Barbiturate withdrawal.
Occurs 2-7 days after last dose.
Agitation.
Hyperreflexia.
Anxiety.
Tremor.

Less often and symptoms are.
Confusion and hallucinations.
Seizures (often refractory to phenytoin).
What are the effects of benzodiazepines on sleep disorders?
The effects of benzodiazepines on sleep disorders.
Decreased tone of upper airway muscles.
Reduction in ventilatory response to carbon dioxide.
Worsening nocturnal hypoxia.
Pulmonary hypertension
What are the effects of inhalation of multiple substances?
Volatile substance inhalation. Produces intoxicating and dysphoric effects within section.
Affect CNS with lethargy, stupor, agitation, hallucinations, dizziness, seizures.
Pulmonary complications include severe respiratory depression, barotrauma, persistent cough, suffocation
what are the most common volatile inhalants?
The most common volatile substance of abuse are.
Paramedic and short-chain hydrocarbons such as
Toluene.
Gasoline.
Butane.
Butyl and animal nitrites.
Freon