Review - Clinical XXVIII (Liver)

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V5.5

[Verse 1: The drums lock into a heavy, stomping march. The Frontman spits the lyrics like a rapid-fire folk tale.]
(Gang Vocals)
Metabolic Dysfunction–Associated Steatotic Liver Disease!
(Frontman)
Cirrhosis; amenorrhea, erectile dysfunction, gynecomastia,
spider telangiectasias, palmar erythema, Dupuytren contractures, and Terry nails!
Hepatorenal syndrome, discontinue diuretics, provide I.V. albumin!
Terlipressin norepinephrine; or oral midodrine plus octreotide!
Hepatic encephalopathy; Lactulose, rifaximin!

[Chorus / The Ascites Shanty: Maximum tavern energy. The accordion blares, and the entire Gang Choir shouts the treatments together in a massive, chantable hook.]
(All Together)
Ascites; paracentesis, spironolactone with furosemide!
Spontaneous bacterial peritonitis; Paracentesis above 250 P.M.N., cultures!
Cefotaxime or ceftriaxone, amoxicillin-clavulanate, and levofloxacin!
Heave away, heave away!

[Verse 2: The electric bass drives a heavy, pulsing rhythm. The fiddle weaves a complex melody behind the vocals.]
(Frontman)
Primary biliary cholangitis; small intrahepatic bile ducts and cholestasis;
fatigue and pruritus then hepatosplenomegaly; women 40–60 years!
A.M.A. and ultrasonography. Biopsy if absent A.M.A.!
Treat with ursodeoxycholic, cholestyramine/fibrates for pruritus, transplant if advanced!
P.S.C.; men aged 20–50, cholestasis, diagnose with M.R.C.P., biopsy not necessary!
For cholangiocarcinoma, semiannual M.R.I. or U.S. or C.A. 19-9!
Ursodeoxycholic, stent, balloon dilation, cholecystectomy, transplant!

[Chorus 2 / The Iron & Copper Chant: The drums shift to a rapid punk-rock double-time beat.]
(Frontman)
Hemochromatosis; after age 50; symmetric arthropathy, hepatic dysfunction,
skin pigmentation, cardiac enlargement, erectile dysfunction and osteoporosis!
Testing for H.F.E. variants. Biopsy, serum biomarkers or elastography to identify advanced fibrosis.
Treat; dietary restrictions, phlebotomy, P.P.I., deferoxamine!
(Gang Vocals)
Wilson disease; 3-55 years!
(Frontman)
Excessive copper absorption from the intestine, decreased excretion by the liver, increased tissue deposition!

[Bridge / The Breakdown: The instrumentation drops to just a stomping foot and clapping hands. The vocals become intensely rhythmic before the band explodes back in.]
(Frontman)
Increased urinary copper and hepatic copper concentration, low serum ceruloplasmin levels.
A.T.P.7.B. or biopsy if needed!
Coombs-negative hemolytic anemia, portal hypertension, and neurologic/psychiatric abnormalities, Kayser-Fleischer!
Treat; diet, D-penicillamine or trientine!

[Verse 3 / The Final Push: The fiddle and accordion play a soaring, frantic duet. The Frontman roars the final etiologies.]
(Frontman)
Budd-Chiari; in hypercoagulable states; R.U.Q. pain, ascites.
Hepatic vein obstruction by caval webs, H.F., constrictive pericarditis, neoplasms.
Treat underlying, anticoagulants, balloon angioplasty, T.I.P.S.!
Sinusoidal obstruction syndrome mimics Budd-Chiari, caused by cytotoxic agents, herbs!

[Outro / The Pub Finale: The tempo accelerates wildly, pushing the musicians to their limit. Everyone shouts the final lines as the song reaches a chaotic crescendo.]
(All Together)
Passive congestion “nutmeg liver” due to right-sided H.F.; increased bilirubin and ascites!
Liver abscess; Fever, R.U.Q. pain, jaundice!
Ceftriaxone and metronidazole ± aspiration!

[Ending: A massive, unified stop on the floor toms and a final, ringing strum of the acoustic guitar. The sound of clinking pint glasses and rowdy cheering fades out. Total silence.]

4143/7500

[Intro: 130 BPM. A lone, lively fiddle plays a rapid jig. Suddenly, the entire band crashes in—heavy drums, accordion, and acoustic guitar galloping at full speed. The Frontman yells out to the crowd to get the song started.] (Frontman) Listen up! Single-question screening for alcohol: “How many times in the past year have you had X or more drinks in a day?” If above 1 then; A.U.D.I.T.! If above 12 alcohol use disorder! Alcohol biomarkers serum phosphatidylethanol and urine ethylglucoronide! Corticosteroids, N-acetylcysteine for alcohol-associated hepatitis! [Verse 1: The drums lock into a heavy, stomping march. The Frontman spits the lyrics like a rapid-fire folk tale.] (Gang Vocals) Metabolic Dysfunction–Associated Steatotic Liver Disease! (Frontman) Cirrhosis; amenorrhea, erectile dysfunction, gynecomastia, spider telangiectasias, palmar erythema, Dupuytren contractures, and Terry nails! Hepatorenal syndrome, discontinue diuretics, provide I.V. albumin! Terlipressin norepinephrine; or oral midodrine plus octreotide! Hepatic encephalopathy; Lactulose, rifaximin! [Chorus / The Ascites Shanty: Maximum tavern energy. The accordion blares, and the entire Gang Choir shouts the treatments together in a massive, chantable hook.] (All Together) Ascites; paracentesis, spironolactone with furosemide! Spontaneous bacterial peritonitis; Paracentesis above 250 P.M.N., cultures! Cefotaxime or ceftriaxone, amoxicillin-clavulanate, and levofloxacin! Heave away, heave away! [Verse 2: The electric bass drives a heavy, pulsing rhythm. The fiddle weaves a complex melody behind the vocals.] (Frontman) Primary biliary cholangitis; small intrahepatic bile ducts and cholestasis; fatigue and pruritus then hepatosplenomegaly; women 40–60 years! A.M.A. and ultrasonography. Biopsy if absent A.M.A.! Treat with ursodeoxycholic, cholestyramine/fibrates for pruritus, transplant if advanced! P.S.C.; men aged 20–50, cholestasis, diagnose with M.R.C.P., biopsy not necessary! For cholangiocarcinoma, semiannual M.R.I. or U.S. or C.A. 19-9! Ursodeoxycholic, stent, balloon dilation, cholecystectomy, transplant! [Chorus 2 / The Iron & Copper Chant: The drums shift to a rapid punk-rock double-time beat.] (Frontman) Hemochromatosis; after age 50; symmetric arthropathy, hepatic dysfunction, skin pigmentation, cardiac enlargement, erectile dysfunction and osteoporosis! Testing for H.F.E. variants. Biopsy, serum biomarkers or elastography to identify advanced fibrosis. Treat; dietary restrictions, phlebotomy, P.P.I., deferoxamine! (Gang Vocals) Wilson disease; 3-55 years! (Frontman) Excessive copper absorption from the intestine, decreased excretion by the liver, increased tissue deposition! [Bridge / The Breakdown: The instrumentation drops to just a stomping foot and clapping hands. The vocals become intensely rhythmic before the band explodes back in.] (Frontman) Increased urinary copper and hepatic copper concentration, low serum ceruloplasmin levels. A.T.P.7.B. or biopsy if needed! Coombs-negative hemolytic anemia, portal hypertension, and neurologic/psychiatric abnormalities, Kayser-Fleischer! Treat; diet, D-penicillamine or trientine! [Verse 3 / The Final Push: The fiddle and accordion play a soaring, frantic duet. The Frontman roars the final etiologies.] (Frontman) Budd-Chiari; in hypercoagulable states; R.U.Q. pain, ascites. Hepatic vein obstruction by caval webs, H.F., constrictive pericarditis, neoplasms. Treat underlying, anticoagulants, balloon angioplasty, T.I.P.S.! Sinusoidal obstruction syndrome mimics Budd-Chiari, caused by cytotoxic agents, herbs! [Outro / The Pub Finale: The tempo accelerates wildly, pushing the musicians to their limit. Everyone shouts the final lines as the song reaches a chaotic crescendo.] (All Together) Passive congestion “nutmeg liver” due to right-sided H.F.; increased bilirubin and ascites! Liver abscess; Fever, R.U.Q. pain, jaundice! Ceftriaxone and metronidazole ± aspiration! [Ending: A massive, unified stop on the floor toms and a final, ringing strum of the acoustic guitar. The sound of clinking pint glasses and rowdy cheering fades out. Total silence.]

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