Acromegaly - Diagnosis and Management Summary - GrepMed Handbook Clinical Presentation: • Classic Acromegaly: frontal bossing, enlarged jaw (macrognathia), ↑ hand + feet size, coarsening facial features, soft tissue swelling and organomegaly - c/f ring tightening, ↑ glove & shoe size, ↑ heel-pad thickness, paresthesias (carpal tunnel) and OSA - Arthralgias, hypertrophic arthropathy • Insidious onset, often undiagnosed for 10+ years. - Usually presents ~5th decade → peripheral/acral enlargement - If GH excess occurs before epiphyseal fusion (children) → Gigantism • Organomegaly: Visceral organs, macroglossia, goiter, LV hypertrophy, colon (↑polyps & malignancy) • Cutaneous: hyperhidrosis, hair growth, skin tags, skin thickening, acanthosis nigricans, cutis verticis gyrata. • Macroadenoma direct effects: Headache (60%), Vision Δs (bitemp hemianopia 10%), HyperPRL (30%), Hypogonad (50%) • Metabolic: Insulin resist + DM, Hyperphosphatemia (70%) • ↑Mortality due to CVD & colon malignancy Pathophysiology: • Acromegaly occurs secondary to GH hypersecretion. • GH stimulates liver IGF-1 (somatomedin C) secretion. GH + IGF-1 → multisystemic anabolic effects with acromegaly and organomegaly. • ~98% - GH-secreting pituitary adenoma (Up to 30% of pituitary adenomas are mixed GH & PRL) • ~2% - Extrapituitary secretion: pancreatic islet cell tumor, excess GHRH release, central (hypothalamic hamartoma) or peripheral (bronchial/abdominal carcinoid or SCLC). Differential Diagnosis (Pseudoacromegaly/Acromegaloid): insulin resistance pseudo-acromegaly, obesity, hypothyroidism, pachydermoperiostosis, drugs (phenytoin, minoxidil), genetic (Beckwith Wiedemann syndrome) Diagnosis and Workup: • Serum IGF-1 level (↑Sens) - GH levels not useful as levels are variable - If IGF-1 equivocal: Oral glucose suppression test → ⨁ if failure to suppress GH levels to <1ng/mL. • Pituitary testing: ↑PRL in mixed adenoma, ↓(TFT, LH, FSH & ACTH) 2/2 adenoma mass effect • Pituitary MRI+contrast Management: • 1st line - Transsphenoidal surgical resection for adenoma • Medical Tx (non-surgical candidates, adjuvant Tx, or post-op residual dz): Somatostatin analogues (Lanreotide) ± GH receptor antagonist (Pegvisomant) ± D2 agonist (Carbergoline) • Radiotherapy: Relapse or refractory cases By Dr. Anuj Thakre (@thakre_anuj) #Acromegaly #Diagnosis #Management #Endocrinology #Treatment #Pathophysiology

Bell's Palsy - Diagnosis and Management Summary - GrepMed Handbook Acute Idiopathic Unilateral Facial Nerve (CN7) Palsy Presentation: • Unilateral upper AND lower facial weakness ± hyperacusis, ↓lacrimation, ↓taste, ↓salivation. • Typical progression: over 1-3d → max severity within 3w, some recovery within 4m • Atypical Features 🚩: - Atypical Clinical: Isolated lower, bilateral, non-CN7 neuropathies (ataxia, hearing loss, spasm, ophthalmoplegia), systemic signs (rash, swelling, adenopathy) - Atypical Temporal: Rapid onset to max severity, prolonged onset (weeks-months), progression >3w, No improvement <4m • Etiology: Idiopathic, HSV most common. Other: viral, Lyme, facial nerve ischemia • DDx: HZV (Ramsay-Hunt), HIV, Lyme, GBS, tumor, parotid/middle ear/skull base pathology, sarcoidosis, Sjogrens Diagnosis and Workup: • No additional workup needed if typical presentation • Lyme Serology (if endemic area) ± HIV screening • Imaging (if atypical symptoms): MRI+gad (stroke, CN7, parotid), CT (middle ear/temporal bone pathology) • LP (if suspect GBS, sarcoid or other CNS inflammatory cause) • EMG/NCS (rare): assist prognosis with delayed recovery Management: • Glucocorticoids: prednisone 60-80mg/d x 1w OR prednisone 60mg x 5d + 10mg taper x 5d • Antiviral (unproven benefit, rec for severe Sx): Valacyclovir 1g tid x 1w or Acyclovir 400 mg 5x/d x 10d • Eyecare (prevent corneal injury): - Awake: Artificial tears gtt qid+prn - Sleep: Artificial tears oint + TAPE eye shut (patch alone may be insufficient!) • Monitoring: New/worsening S/Sx after 3w, no improvement within 4m #Bells #Palsy #Diagnosis #Management #Treatment #Neurology

Hyperkalemia - Diagnosis and Management - GrepMed Handbook S/Sx: Most pts asymptomatic. Weakness, cramping, nausea, paresthesias, palpitations, bradycardia, arrhythmias Etiology: • Medications: K+, ACEi/ARBs, NSAIDs, β-blockers, Antibiotics (Bactrim, PCN G-K), K-sparing diuretics, Saline infusion, Calcineurin inhibitors, Digoxin, Succinylcholine • Redistribution: Acidosis, Cell Lysis (TLS, rhabdo/crush injury, ischemia, hemolysis, transfusions), ↓insulin (DM, DKA, octreotide), hyperK periodic paralysis, post-hypothermia • ↓ Renal K+ Excretion: - Renal Failure, esp w oliguria / GFR<15 - ↓ Effective arterial volume (↓distal Na delivery): CHF, cirrhosis, hypovolemia - ↓ Renin/Aldosterone, RTA Type IV, AI • Ureterojejunostomy (reabsorption) Workup: • Assess for Pseudohyperkalemia - hemolysis, tourniquet / IVF line draw, ↑↑Plts or ↑↑WBC (use heparinized tube) • ECG (↓Sens but Δs indicate badness): Peak T, flat P, ST depress, ↑PR ↑QRS intervals, bradycardia → sine wave → PEA/VF • Labs: BMP (Assess GFR), ±VBG (acidosis), CK+LDH (lysis) ± Urine Lytes: UNa < 20 suggests ↓ distal Na delivery, UK:Cr < 15 suggests ↓ renal excretion ± Renin/Aldosterone levels, Cortisol+ACTH stim test (only if no clear cause) Management: • Stabilization, Redistribution and Elimination (see Table below) • STOP offending medications (review MAR) • Optimize volume status to improve GFR - Diuresis (hypervolemia) - IVF (hypovolemia) - Use LR/Plasmalyte (Bicarb≥22) or isotonic bicarbonate gtt (Bicarb<22) - avoid NS (→hyperchloremic acidosis) • Low K diet Stabilization Treatments: • Calcium 2-3g IV Ca-gluconate or 1g CaCl- (central line) - 1st line, stabilizes cardiac membrane. - Transient, repeat dose PRN (ongoing arrhythmia). Redistribution Treatments: • Insulin 5-10U reg IV + 1-2 amps D50W - Drives K+ into cells. Give D50 before insulin. Monitor hypoglycemia • Albuterol 10-20 mg neb or 0.5 mg IV, Terbutaline 7 µg/kg SC (~0.5 mg) - Give albuterol as a continuous neb. Monitor for tachycardia • Epinephrine IV - Only if concurrent need for vasopressor or HyperK-induced bradycardia • Isotonic Bicarbonate gtt - Only in acidosis. Use gtt, NOT hypertonic Amp IVP • Diuretics (IV loop diuretic ± thiazide / acetazolamide) - IV loop diuretic (lasix ≥ 60 mg) alone may be sufficient if intact GFR. - IVF as needed to avoid hypovolemia Elimination Treatments: • K-Binding Resins - Exchanges K+ for cations in gut. Slow - don’t delay HD - Na-Zirconium (10g PO tid) - caution in HTN & edema - SPS (15-60g PO/PR) - avoid ileus/obstruction (ischemia/necrosis), limited evidence for effectiveness - Patiromer (8.4-25.2 g/d PO) • Hemodialysis - Definitive in ESRD or failure of other measures Check out https://emcrit.org/ibcc/hyperkalemia/ for a definitive guide to diagnosis and management of hyperkalemia #Hyperkalemia #Diagnosis #Management #Treatment #potassium #nephrology #K

Heparin Induced Thrombocytopenia (HIT) - Diagnosis and Management - GrepMed Handbook Presentation: • Plts ↓50% (nadir ~40-80k) after 5-10d, venous (DVT/PE) or arterial thrombosis, skin necrosis (at injection sites) ↑ Risk Factors: • SICU > MICU, ♀, ↑Age, ESRD Pathophysiology: • IgG binds heparin-PF4 complex → plt activation and PF4 release → hypercoagulable state and plt consumption → thrombocytopenia Diagnosis: • Clinical Suspicion → Calculate 4T score (0-8). • If 4T score ≥ 4, obtain Anti-PF4 Ab titer (ELISA) - ↑Sens/↓Spec → Significant false ⊕’s, so use Bayesian approach for post-test probability (IBCC). • Serotonin Release Assay (SRA): Confirmatory test ↑Se/Sp but very slow - do not wait to treat if high suspicion. Management: • D/c all heparin (including flushes), reverse any warfarin exposure (prevent skin necrosis) • Start non-heparin A/C if clinical thrombosis or high likelihood of HIT: Argatroban, Fondaparinux, Bivalirudin, DOAC • A/C Duration: ⊕Thrombosis: 6 months ⊖Thrombosis: Min until Plts recover, consider a/c 2-3m (↑ thrombosis w/in 30d) • H/o HIT: Can consider re-challenge >100d after Dx if PF4-Ab⊖ or SRA⊖. Check out https://emcrit.org/ibcc/thrombocytopenia/#heparin_induced_thrombocytopenia for a definitive guide to diagnosis and management of HIT #HIT #Heparin #Induced #Thrombocytopenia #Diagnosis #Management #Treatment #Hematology #HemeOnc

C.diff - Clostridioides Difficile Infection (CDI) - Diagnosis and Management - GrepMed Handbook Clinical Presentation + Progression: • Asymptomatic Colonization (~20% of hospitalized pts on ABx) → Acute Diarrhea (>3 BM/d) ± blood/mucus, Abd pain, Fever, ↑WBC → Pseudomembranous colitis (wall thickening) → Fulminant Colitis (Ileus, Toxic Megacolon, Shock, Perforation) Pathophysiology: Spore ingestion → colonic colonization → proliferation (Abx or chemo) → toxin A/B release → mucosal inflammation and necrosis → pseudomembranes and toxic megacolon Epidemiology: • #1 nosocomial infection up to 10w post-ABx, but can be community-acquired w/o ABx (esp elderly, immunocompromised, IBD) • ↑Risk: clindamycin, quinolones, cephalosporins, carbapenems. Lowest Risk: Tetracyclines Diagnosis: • Stool toxin immunoassay (↑Spec) - Toxin A/B • GDH - Glutamate Dehydrogenase (↑Sens) - produced by all strains, including non-toxigenic • Stool PCR (↑Sens, false ⊕ in colonization, non-toxigenic) - often ordered in reflex if immunoassay equivocal • CT A/P: Assess complications (megacolon, perforation). • KUB ↓↓Sens for complications. • Flex-Sig: If diagnostic uncertainty (Bx) or no improvement with Tx Management (IDSA 2021): • Note: Fidaxomicin is now preferred over vancomycin (limited by $) • d/c offending ABx if possible - otherwise continue Tx for 7d post-Abx • Initial CDI Episode: - Preferred: Fidaxomicin 200 mg PO bid x 10d - Alternative: Vancomycin 125 mg PO qid x 10d • 1st CDI Recurrence • ≥ 2nd CDI Recurrence • Fulminant CDI (Ileus, Megacolon, Shock, Perforation) • Bezlotoxumab 10 mg/kg IV x 1 - Adjunct Tx given along with above regimens for recurrent CDI • Fecal Microbiota Transplant (FMT) - consider if 2 recurrences despite appropriate treatment • Prophylaxis: Vancomycin 125 mg PO qd - If needing ABx or h/o recurrent/severe CDI IDSA 2021 CDI Treatment Guideline: https://doi.org/10.1093/cid/ciab549 #CDI #Cdiff #Clostridioides #Difficile #Clostridium #Infection #diagnosis #management #treatment #infectiousdiseases #IDSA #gastroenterology

Helicobacter Pylori (H. pylori) Infection - Diagnosis and Management - GrepMed Handbook Presentation: Dyspepsia / Peptic Ulcer Disease Epidemiology: Unusual in children, up to 50% of adults +serology in developed countries Microbiology: • spiral shaped, microaerophilic, gram negative bacterium • Urease (hydrolyze urea to create neutralizing NH4+), shape and flagella allow adaptation to gastric mucosa • Transmission unknown (presumed fecal-oral or oral-oral) Diagnosis: • Endoscopic Biopsy (definitive) • Stool Ag, Urea Breath Testing (UBT) - ↑ false ⊖ on antacids, hold 2w before testing if possible • Serology (IgG) - cannot differentiate past infection Management: • 1st Line - Quadruple Therapy (14d) - PPI bid, Bismuth 300mg qid, Tetracyline 500mg qid (or doxy 100mg bid), Metronidazole (250 qid or 500 tid) - PPI bid, Clarithromycin 500mg bid, Tetracyline 500mg qid (or doxy 100mg bid), Metronidazole (250 qid or 500 tid) • Triple Therapy (14d) - PPI BID, Clarithromycin 500mg bid, Amoxicillin 1g bid (or flagyl 500mg TID if PCN-allergy) • Confirm Eradication (due to increased ABx resistance): Stool Ag, Urea Breath Test or repeat EGD #Helicobacter #Pylori #hpylori #Diagnosis #Management #Treatment #quadruple #therapy #triple #quadrupletherapy #gastroenterology

Acute Pancreatitis - Diagnosis and Management - GrepMed Handbook Presentation: • Epigastric abdominal pain (90%, characteristically radiating to back), N/V (90%) • Other: Jaundice (obstruction), Periumbilical (Cullen) or flank (Grey-Turner) bruising in severe hemorrhagic. Etiology: • Gallstones (40-50%), EtOH (30%), Hypertriglyceridemia 10%), HyperCa2+ • Other: ERCP/surgery, Trauma, Drugs, Autoimmune, PUD (posterior), Anatomic (divisum/annular pancreas, sphincter dysfunction), Familial, Infectious, Ischemia, Cancer/Mets, Radiation, Cystic Fibrosis Diagnosis (2 of 3): 1) Characteristic presentation 2) Lipase > 3x ULN 3) Imaging findings Workup: • Labs: Lipase, Ca2+, LFTs, Triglycerides (>1000 mg/dL) • Imaging: US (biliary evaluation, gallstones), CT (early only to clarify diagnosis, can be normal early; late to assess for complications), MRCP (necrosis, biliary, stones), CTA if suspect hemorrhage Management: • IVF - Moderate fluid resuscitation in first 24h • Analgesia: Scheduled APAP, IV Opioids (can worsen ileus), consider pain-dose ketamine (ICU); consider epidural if available. • Nutrition: Early enteral improves outcomes, consider NGT if unable to tolerate within 48-72h. Can immediately start with low-fat (as safe as CLD). Avoid TPN. • Antibiotics: AVOID • Gallstones: Urgent ERCP (w/in 24h) if cholangitis, consider ERCP + cholecystectomy during hospitalization • HyperTrig: D10+insulin gtt (goal TG < 500-1000, closely monitor electrolytes), gemfibrozil 600 bid • HyperCa2+: Bisphosphonates, calcitonin • Infected Necrosis - Dx: FNA if suspected. Tx: ABx (pip-tazo, carbapenem or cefepime+flagyl) ± drainage. Check out https://emcrit.org/ibcc/pancreatitis/ for a definitive guide to diagnosis and management of pancreatitis (and discussion of fluid management) #Pancreatitis #Acute #Diagnosis #Management #Treatment #Gastroenterology