Biomedical subjects

Nelson Garcia

Publications and source records attributed to Nelson Garcia.

2 recordsLinked to original sources

PubMed2001

Ascites.

Ascites is the most common presentation of decompensated cirrhosis, and its development heralds a poor prognosis, with a 50% 2-year survival rate. Effective first-line therapy for ascites includes sodium restriction (2 g/d), use of diuretics, and large-volume paracentesis (LVP). Ideally, a combination of a loop-acting diuretic (eg, furosemide) and a distal-acting diuretic (eg, spironolactone) is used. LVP has the advantage of producing immediate relief from ascites and its associated symptoms. When 5 L or more ascitic fluid is removed, albumin (6 to 8 g per liter of fluid removed) should be administered intravenously to minimize hemodynamic and renal dysfunction. The development of refractory ascites is particularly ominous, and 50% of such patients die within 6 months of its development. Liver transplantation is the only effective therapy for patients with refractory ascites associated with cirrhosis; unfortunately, this therapy is not available for many of those with refractory ascites. Other therapies that are available include LVP, peritoneovenous shunts, and transjugular intrahepatic portasystemic shunts (TIPS). LVP alleviates ascites rapidly, but ascites recurs universally, requiring repeated hospitalizations and paracenteses and decreasing patient quality of life. Peritoneovenous shunts rarely are used due to their high complication rate and tendency to become occluded. Recently, the use of TIPS has been shown to be an effective therapy for patients with refractory ascites. It is most effective when liver function is relatively well preserved. On the other hand, TIPS may hasten death in those with advanced liver failure. TIPS has not been shown to have a clear-cut beneficial effect on survival in patients with refractory ascites. Spontaneous bacterial peritonitis is the most common complication of ascites and is associated with a worsening hyperdynamic circulation and a mortality rate of approximately 20%. Following an episode of spontaneous bacterial peritonitis, the 1-year mortality rate approaches 70%. Patients at risk should be considered for prophylaxis with an orally administered quinolone (eg, norfloxacin). Alternatives include trimethoprim/sulfamethoxazole. Active spontaneous bacterial peritonitis should be treated with an intravenously administered third-generation cephalosporins (eg, cefotaxime) in most circumstances.

Journal Article↗

PubMed2001

Portal Hypertensive Gastropathy and Gastric Antral Vascular Ectasia.

Portal hypertensive gastropathy (PHG) causes both acute and chronic blood loss from the gastrointestinal tract in patients with portal hypertension. Gastric antral vascular ectasia (GAVE) is a distinct condition also associated with portal hypertension that can cause acute and chronic upper gastrointestinal blood loss. These conditions frequently, but not invariably, are diagnosed by upper endoscopy. Although they are fairly prevalent, only 15% to 20% of subjects experience symptomatic gastrointestinal blood loss. Acute gastrointestinal bleeding from PHG should first be treated with octreotide (100 mg bolus intravenously, followed by a 50 mg/h continuous intravenous infusion). If the bleeding does not stop or slow down appreciably within 24 to 48 hours, propranolol may be administered orally to those patients who are hemodynamically stable. Propranolol should be started at 40 mg/d orally in two divided doses. If the patient can tolerate the propranolol and is still bleeding, the dosage may be titrated up to the maximum tolerated amount. For those subjects who are unable to tolerate beta-blockers or continue to bleed despite beta-blocker therapy, transjugular intrahepatic portosystemic shunt (TIPS) is the next line of treatment. Portal decompressive surgery is reserved for those who are not candidates for TIPS and where the appropriate expertise is available. Prevention of chronic gastrointestinal blood loss from PHG should be attempted with beta-blockers, with the dosage titrated up to achieve a resting heart rate of approximately 60 beats per minute. In patients who do not respond to beta-blockers, a TIPS should be placed. The role of long-acting release octreotide in this setting is experimental. The primary treatment of actively bleeding GAVE as well as recurrent bleeding from GAVE is endoscopic ablation of the lesion using either argon plasma coagulation, neodymium:yttrium-aluminum-garnet (Nd:YAG) laser, or heater probe. TIPS and beta-blockers are ineffective for the long-term prevention of recurrent bleeding from GAVE. For selected patients with severe recurrent bleeding or uncontrollable acute bleeding from GAVE, an antrectomy with Billroth I anastomosis may be considered.

Journal Article↗