General medicine: CL Lai Session 3

Question 1

Causes of sudden hypoglycemia

Answer 1

• 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

Question 2

Mx of gout

Answer 2

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,

Question 3

How to screen for HCC?

Answer 3

Done every 6 months
USG better than AFP
AFP: 70% sensitivity

Question 4

HCC criteria for liver transplantation

Answer 4

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

Question 5

Hepatic resection recurrence after HCC

Answer 5

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)

Question 6

How many patients with HCC dont have cirrhosis in HBV?
Can alcohol and HCV cause HCC without cirrhosis?

Answer 6

• 20-30% dont have cirrhosis
• Alcohol and HCV can only cause HCC by causing cirrhosis first

Question 7

How to manage HCC

Answer 7

• 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)

Question 8

Tace procedure

Answer 8

Procedure: mix lipiodol (fat + iodinated contrast) with chemotherapeutic agents (cisplatin or doxorubicin), injected directly into hepatic artery, and embolise with gelfoam

Question 9

Mechanism behind TACE

Answer 9

1. Lipiodol is preferentially uptaken by Kupffer cells in liver tumor (or lymphatics)
2. Lipiodol is retained in these cells for months to years causing a prolonged action
3. Gelfoam prevents diffusion of lipiodol and chemo out of hepatic artery
4. Gelfoam imposes partial (not complete, so can repeat TACE) ischemia and necrosis of tumor
5. Chemotherapeutics administered via hepatic artery (HCC is supplied by hepatic artery vs. 25% in
   normal liver tissue) to minimize damage to non-tumor liver
6. Chemotherapeutics administered via hepatic artery to reduce systemic side effects compared by IV

Question 10

AE of TACE

Answer 10

1. Post-TACE syndrome: fever, pain, nausea and vomiting
2. Rise in AST/ALT (due to tumor necrosis)
3. Liver failure (30%): increase in bilirun and PT, if severe causing ascites and encephalopathy 4. Local hematoma
4. Local infection: after TACE patients usually covered by antibiotics, if fever persists > 1 week, do USG to rule out abscess formation
5. Acalculous cholecystitis
6. Intestinal ischemia (disturbances in coeliac blood flow distribution during manipulation) 8. (Non-specific) contrast nephropathy

Question 11

Contraindications to TACE

Answer 11

1. 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.
2. Poor liver function (bilirubin > 50)
3. Severe A/V shunting (TACE no longer effective, and probably distant metastasis has occurred
4. Diffuse or large (> 10c,) HCC, or distant metastasis – TACE simply futile

Question 12

Alternatives to TACE

Answer 12

1. Transarterial radioembolization i.e. yttrium-90
2. Sorafenib – multi-kinase inhibitor, anti-angiogenesis, for palliation and partial remission
    S/E: diarrhea, rash on hands and feet)
3. 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