General medicine: CL Lai Session 3 Flashcards
Causes of sudden hypoglycemia
- Addisonian crisis
- Alcohol
- Paraneoplastic syndrome (HCC (but not common due to screening now), mesothelioma)
- Insulinoma
- Sarcoma
- Post surgical dumping syndrome (partial gastrectomy: moves through the GI too fast)
Cortisol causes eosinophilia to go into bone marrow. If lack of cortisol –> causes elevated eosinophilia
Mx of gout
NSAIDs
Colchicine: inhibits mitosis. AE: diarrhea
Allopurinol. AE: skin hypersensitivity, rare is SJS.
Febuxostat. AE: liver failure, cardiovascular event
Low purine diet, restrict red meat,
How to screen for HCC?
Done every 6 months
USG better than AFP
AFP: 70% sensitivity
HCC criteria for liver transplantation
1 tumor not more than 5cm
3 tumors each not larger than 3cm and together not >8cm
Recurrence rate is higher if does not fulfill this criteria
Hepatic resection recurrence after HCC
50% recurrence within 2 years
There may be micrometastasis
De novo lesions (DNA fingerprinting)
Tumor field cancerization (gene X is oncogenic: transactivator of gene expression)
How many patients with HCC dont have cirrhosis in HBV?
Can alcohol and HCV cause HCC without cirrhosis?
- 20-30% dont have cirrhosis
- Alcohol and HCV can only cause HCC by causing cirrhosis first
How to manage HCC
- Best is liver transplantation (milan criteria)
- Hepatic resection (assess liver function by child pugh score. Recurrence rate is 70% in 2 years)
- Local ablative techniques: radiofrequency ablation, microwave, HIFU, cryoablation (>3cm and not near vessels)
- TACE (transcatheter arterial chemoembolization)
Tace procedure
Procedure: mix lipiodol (fat + iodinated contrast) with chemotherapeutic agents (cisplatin or doxorubicin), injected directly into hepatic artery, and embolise with gelfoam
Mechanism behind TACE
- Lipiodol is preferentially uptaken by Kupffer cells in liver tumor (or lymphatics)
- Lipiodol is retained in these cells for months to years causing a prolonged action
- Gelfoam prevents diffusion of lipiodol and chemo out of hepatic artery
- Gelfoam imposes partial (not complete, so can repeat TACE) ischemia and necrosis of tumor
- Chemotherapeutics administered via hepatic artery (HCC is supplied by hepatic artery vs. 25% in
normal liver tissue) to minimize damage to non-tumor liver - Chemotherapeutics administered via hepatic artery to reduce systemic side effects compared by IV
AE of TACE
- Post-TACE syndrome: fever, pain, nausea and vomiting
- Rise in AST/ALT (due to tumor necrosis)
- Liver failure (30%): increase in bilirun and PT, if severe causing ascites and encephalopathy 4. Local hematoma
- Local infection: after TACE patients usually covered by antibiotics, if fever persists > 1 week, do USG to rule out abscess formation
- Acalculous cholecystitis
- Intestinal ischemia (disturbances in coeliac blood flow distribution during manipulation) 8. (Non-specific) contrast nephropathy
Contraindications to TACE
- Pre-existing or impending portal venous thrombosis so non-tumor liver solely depends on hepatic artery. If patient is young, do TAC without E, but this is risky.
- Poor liver function (bilirubin > 50)
- Severe A/V shunting (TACE no longer effective, and probably distant metastasis has occurred
- Diffuse or large (> 10c,) HCC, or distant metastasis – TACE simply futile
Alternatives to TACE
- Transarterial radioembolization i.e. yttrium-90
- Sorafenib – multi-kinase inhibitor, anti-angiogenesis, for palliation and partial remission
S/E: diarrhea, rash on hands and feet) - IFN therapy for HCC, higher dose than HBV/HCV infection, complete tumor regression in CT up to 30% in HKU study? Mechanism: inhibition of angiogenesis in tumor, immunostimulation, direct induction of cell dea