I gave a lecture at the refresher course last Monday. Two days later, I received a list of questions from a student. I have never answered questions in my blog before, but then I have never received so many questions from a student all at once either. The questions are practical and insightful and should be shared with other students.
1. I was told that in liver cirrhosis progression, it usually starts with deranged clotting profile, then albumin, then bilirubin, then ascites and finally encephalopathy. Is that true that when patient developed, let's say, ascites or encephalopathy, it indicates a more severe cirrhosis?
Answer: The sequence of laboratory changes is not absolute. However, it is true that clinical complications such as ascites and encephalopathy usually indicate more severe disease and are associated with poor prognosis.
2. In monitoring patients with cirrhosis, do we monitor by Child-Pugh grading + HCC surveillance + varices screening + hepatorenal syndrome screening? Do we need to repeat ultrasound for progression of features?
Answer: You have included different concepts here: assessment of the severity of cirrhosis and complications screening. Currently, most doctors use the Child-Pugh score or the model for end-stage liver disease (MELD) score to assess the severity of cirrhosis. The purpose is to predict the prognosis and prioritize patients for liver transplantation.
HCC surveillance is performed to detect early HCC so that patients may receive curative treatment. That said, this should only be done in patients who are candidates for curative treatment. For example, a patient with Child’s C cirrhosis and multiple comorbid illnesses cannot undergo liver resection or locoregional therapy even if a small HCC is detected. Surveillance would not be helpful.
Screening for varices is also recommended to reduce the risk of variceal bleeding.
Finally, the main role of ultrasound is for HCC surveillance. We use other parameters to assess the severity of cirrhosis.
3. Once patient is diagnosed to have liver cirrhosis, when should we start screening for varices? and by what mean? Ultrasound or endoscopy?
Answer: Unless the patient is moribund, all cirrhotic patients should be screened for varices by OGD.
4. When we say ultrasound imaging to look for presence of varices, do we mean hepatic doppler ultrasound that the flow in different hepatic vasculature may suggest the presence of esophageal varices?
Answer: In good hands, splenic varices may be visualized by ultrasound. While this feature confirms the presence of portal hypertension, it cannot replace OGD. It is bleeding from esophageal or gastric varices that we want to prevent.
5. For HCC surveillance, do you mean serum AFP + LFT + CT (or USG?) scan regularly?
Answer: Good question. For some hepatologists, this means 6-monthly USG and AFP testing. Liver function test does not detect HCC. CT is more accurate but involves radiation and has not been tested in the screening setting. Triphasic CT is usually reserved for confirming the diagnosis of HCC when a liver nodule is identified by USG. Interestingly, the current American guidelines only suggest USG surveillance and discourage the use of AFP. This is highly debatable.
6. In bleeding esophageal varices, do we need to give both octreotide and terlipressin together? What is the usual dosage given and are they given as IV infusion or bolus?
Answer: Either somatostatin analog (e.g. octreotide) or vasopressin analog (e.g. terlipressin) would do. The dosage we are using is octreotide 50 mcg iv stat, followed by 50 mcg/h infusion; and terlipressin 2 mg Q4-6H iv. There have also been studies showing that terlipressin infusion may be better than bolus injections.
7. In variceal bleeding, do we need to correct the deranged clotting profile by transfusing fresh frozen plasma? and also correct any platelet derangement?
Answer: Many doctors do so, but this practice is not adequately tested.
8. Do we need to prophylactically give lactulose to all cirrhotic patients with variceal bleeding to prevent development of hepatic encephalopathy? or do we give only when patients develop symptoms and signs of HE?
Answer: Because patients with variceal bleeding are at high risk of developing hepatic encephalopathy and lactulose carries few side effects, we usually give it prophylactically.
9. In secondary prophylaxis of variceal bleeding, you mentioned an option of endoscopic variceal ligation, but I thought you have already banded all varices during last variceal bleeding? or do you mean those new varices developed? Also, do we need to start beta blocker +/- nitrate immediately after first episode of variceal bleeding?
Answer: It takes an average of 5 sessions to eradicate all esophageal varices. A clinical trial from Spain showed that pharmacological therapy is more effective than endoscopic variceal ligation for secondary prevention of variceal bleeding and result in less complications (N Engl J Med 2001;345:647-55). However, a subsequent meta-analysis showed that combining endoscopic variceal ligation and pharmacological therapy would further reduce the chance of rebleeding (Aliment Pharmacol Ther 2012;35:1155-65). At our center, we do both.
Immediately after variceal bleeding, the patient should still be on vasoactive drugs such as octreotide or terlipressin. You do not need to start beta-blockers yet. Besides, it is a bad idea to give a drug that would lower the blood pressure right after active bleeding. Instead, beta-blockers and/or nitrates may be started after the acute episode settles.
10. If we are to give lactulose to patient during variceal bleeding, since patients are kept NPO, can he still tolerate an oral lactulose? How about in the case when patient is drowsy and confused as in grade 2-3 encephalopathy or patient in hemorrhagic shock, is it still safe to give oral lactulose?
Answer: We can keep the patient nil by mouth except medications. If the patient has aspiration risk, medications should be delivered via nasogastric tube instead.
11. In patients with ascites with deranged renal function (creatinine >133), do we routinely stop diuretics or paracentesis for 2 days to assess hepatorenal syndrome?
And even with albumin infusion, ascites will still come back right? And is this because hypoalbuminemia is not related to pathophysiology of ascites? And in this case, do we just leave the ascites untreated and observe?
Answer: It is important to stop diuretics and paracentesis in cirrhotic patients with acute kidney injury. They may well be the culprit.
Albumin infusion is for the prevention of paracentesis-induced circulatory dysfunction, not ascites. Therapeutic paracentesis relieves ascites rapidly but does not alter the underlying pathophysiology of portal hypertension and salt retention. Therefore, ascites will recur after paracentesis unless the patient is well controlled with salt restriction and diuretics. However, some patients will still have refractory ascites and require either repeated paracentesis or TIPS.
12. I'm sorry to complicate the case further. What if the patient has co-morbid cardiovascular condition (eg. hypertension, heart failure) that requires the use of diuretics? Do we still stop it for assessment? If patient is on ACEI, do we need to stop it for HRS assessment?
Answer: You have to assess the fluid status. If the patient is having fluid overload, you do not have much choice. For your last question, cirrhotic patients are very sensitive to ACEI because renal perfusion is often suboptimal. In case of renal deterioration, we have low threshold to stop ACEI.
13 Jun 2013
6 Jun 2013
Present
Curiously, this is the first time I wrote on my blog on our anniversary. This year is also special in that my brother Roy is getting married later this month.
Roy reminds me much of Levin in Anna Karenina. He expressed how pointless the wedding preparation and ceremony were, but ended up doing everything others did. I wish he would enjoy it as much as Levin did in the end.
Every Christmas, our parish priest tells us a story about love. Every Christmas, he tells the same story.
Once there was a poor couple. The husband had a watch, but it had no straps. One Christmas, the wife gave him a pair of leather straps as present. The man was very surprised, “How did you get the money?” The wife replied that she sold her hair. The man then gave her a present. It was a beautiful comb. This time, it was the wife who was surprised. “I sold my watch,” the man explained.
At this point, Angelina commented, “You can still use the comb with short hair. Besides, the hair can grow back. The man was less lucky.” I replied, “I think he was very lucky. The present was love.”
Roy reminds me much of Levin in Anna Karenina. He expressed how pointless the wedding preparation and ceremony were, but ended up doing everything others did. I wish he would enjoy it as much as Levin did in the end.
Every Christmas, our parish priest tells us a story about love. Every Christmas, he tells the same story.
Once there was a poor couple. The husband had a watch, but it had no straps. One Christmas, the wife gave him a pair of leather straps as present. The man was very surprised, “How did you get the money?” The wife replied that she sold her hair. The man then gave her a present. It was a beautiful comb. This time, it was the wife who was surprised. “I sold my watch,” the man explained.
At this point, Angelina commented, “You can still use the comb with short hair. Besides, the hair can grow back. The man was less lucky.” I replied, “I think he was very lucky. The present was love.”
30 May 2013
Deserve
There are four potential theories of distribution justice.
The feudal or caste system is the most unjust. Whether a person ends up being a prince or a slave depends solely on the luck at birth but not what he does.
The libertarian system or free market appears to offer equal opportunities, but this is not entirely so. If children from rich families are more likely to receive good education and job opportunities, they still have a huge advantage over poorer people.
In some countries, this potential flaw is tackled by the meritocratic approach. This attempts to offer fair equality of opportunity. For example, the government may provide equal educational opportunities for both the rich and the poor. In USA and China, children of ethnic minorities are even preferentially admitted to the college. (Of course, ethnic minorities are not necessarily poorer. That would be another topic.)
However, John Rawls (1921-2002) argued that even the meritocratic approach cannot totally eliminate inequality. You may provide opportunities to the disadvantaged, but you cannot prevent the fastest runners from winning a race and the cleverest students from entering college. To a certain degree, being fast or clever is also a matter of luck similar to being born in a rich family. The society still produces the retired professor who found no problem in charging his patient an outrageous sum.
Now, you may argue that your success is not the sole result of talent and upbringing; you have worked very hard to achieve what you have today. Rawls would counter by saying that even effort may be the product of a favorable upbringing. Besides, the society pays for your achievements, not your hard work. In this world, there must be soccer players who practise even harder than David Beckham and remain unheard of, but you probably would not advocate that they should be the richest soccer players instead.
Rawls is not saying that successful people should not earn more. This would take away the incentives to work hard and excel. Instead, he wants us to understand that while we are entitled to what we have, we should remain humble and not to think we deserve everything. Instead, earning more is justifiable only if we at the same time help less fortunate people.
The feudal or caste system is the most unjust. Whether a person ends up being a prince or a slave depends solely on the luck at birth but not what he does.
The libertarian system or free market appears to offer equal opportunities, but this is not entirely so. If children from rich families are more likely to receive good education and job opportunities, they still have a huge advantage over poorer people.
In some countries, this potential flaw is tackled by the meritocratic approach. This attempts to offer fair equality of opportunity. For example, the government may provide equal educational opportunities for both the rich and the poor. In USA and China, children of ethnic minorities are even preferentially admitted to the college. (Of course, ethnic minorities are not necessarily poorer. That would be another topic.)
However, John Rawls (1921-2002) argued that even the meritocratic approach cannot totally eliminate inequality. You may provide opportunities to the disadvantaged, but you cannot prevent the fastest runners from winning a race and the cleverest students from entering college. To a certain degree, being fast or clever is also a matter of luck similar to being born in a rich family. The society still produces the retired professor who found no problem in charging his patient an outrageous sum.
Now, you may argue that your success is not the sole result of talent and upbringing; you have worked very hard to achieve what you have today. Rawls would counter by saying that even effort may be the product of a favorable upbringing. Besides, the society pays for your achievements, not your hard work. In this world, there must be soccer players who practise even harder than David Beckham and remain unheard of, but you probably would not advocate that they should be the richest soccer players instead.
Rawls is not saying that successful people should not earn more. This would take away the incentives to work hard and excel. Instead, he wants us to understand that while we are entitled to what we have, we should remain humble and not to think we deserve everything. Instead, earning more is justifiable only if we at the same time help less fortunate people.
23 May 2013
Utility
For libertarians, the question is quite unworthy for discussion. So far as the patient is willing to pay and there is no coercion or deceit, charging dearly is not wrong. For instance, you would not object to Lionel Messi’s salary however high it may be. Libertarians favor free market. People should be free to decide what to do with their money. Taxation is unjust because it jeopardizes the ownership. To go one step further, libertarians also believe that people own their bodies and their lives, and therefore do not support moral laws such as those against prostitution.
In contrast, the utilitarian philosophy considers how we may maximize happiness and minimize pain. For example, Jeremy Bentham proposed building beggar workhouses in the 18th century. According to the scheme, beggars in the streets were to be locked up. They would then have to work to pay for the expenses of the workhouses. Bentham reasoned that other citizens would be happier with no beggars in the streets, at a small cost of a few beggars who might be forced to live in places they did not like. The overall happiness, or utility, of the society would nevertheless increase.
At first glance, we may think that utilitarians must support low doctor fees. Patients would be happier, or at least feel less pain, if they can pay less for the same service. However, utilitarians would point out that it depends on whether lowering doctor fees would result in fewer competent doctors joining the profession and deteriorating health care. In the latter case, the utility of the society would actually decrease.
Utilitarian principles are difficult to apply. Above all, happiness cannot be quantified but utilitarians try to measure everything in the same scale. Even if measurement is possible, a popular policy among the majority does not mean it is right. In the era of the Roman Empire, prisoners were forced to fight with tigers and die a brutal death for the entertainment of Roman citizens. Tens of thousands of people were enchanted at the expense of a few prisoners who would die from other punishments anyway, but yet we find the practice hard to accept. Surely overall or average happiness cannot be the sole yardstick we go after.
In contrast, the utilitarian philosophy considers how we may maximize happiness and minimize pain. For example, Jeremy Bentham proposed building beggar workhouses in the 18th century. According to the scheme, beggars in the streets were to be locked up. They would then have to work to pay for the expenses of the workhouses. Bentham reasoned that other citizens would be happier with no beggars in the streets, at a small cost of a few beggars who might be forced to live in places they did not like. The overall happiness, or utility, of the society would nevertheless increase.
At first glance, we may think that utilitarians must support low doctor fees. Patients would be happier, or at least feel less pain, if they can pay less for the same service. However, utilitarians would point out that it depends on whether lowering doctor fees would result in fewer competent doctors joining the profession and deteriorating health care. In the latter case, the utility of the society would actually decrease.
Utilitarian principles are difficult to apply. Above all, happiness cannot be quantified but utilitarians try to measure everything in the same scale. Even if measurement is possible, a popular policy among the majority does not mean it is right. In the era of the Roman Empire, prisoners were forced to fight with tigers and die a brutal death for the entertainment of Roman citizens. Tens of thousands of people were enchanted at the expense of a few prisoners who would die from other punishments anyway, but yet we find the practice hard to accept. Surely overall or average happiness cannot be the sole yardstick we go after.
16 May 2013
Bill
Most of us cannot accept what Chopper did. Doctors should not earn money by doing unnecessary and harmful procedures.
In that case, let me tell you another story.
A retired professor performed a 5-minute procedure for a rich man. The accounting clerk saw the bill and was astonished. That was the price of a brand new car. Summoning her courage, the clerk called the professor and asked if he might have added an extra zero by mistake. (She wanted to say two zeroes but thought better of it.)
The professor answered, “I am a famous doctor and he is a rich man. What is the problem with that?”
Now, is this acceptable? This time, the professor did a legitimate albeit simple procedure. Money did not bias his clinical decision. In fact, one may even argue that if he can charge whatever he likes for such minor tasks, the chance for him to offer unnecessary interventions would be lower.
In that case, let me tell you another story.
A retired professor performed a 5-minute procedure for a rich man. The accounting clerk saw the bill and was astonished. That was the price of a brand new car. Summoning her courage, the clerk called the professor and asked if he might have added an extra zero by mistake. (She wanted to say two zeroes but thought better of it.)
The professor answered, “I am a famous doctor and he is a rich man. What is the problem with that?”
Now, is this acceptable? This time, the professor did a legitimate albeit simple procedure. Money did not bias his clinical decision. In fact, one may even argue that if he can charge whatever he likes for such minor tasks, the chance for him to offer unnecessary interventions would be lower.
9 May 2013
Chopper
Recently, my friend told me a story about Chopper.
Chopper, as you may imagine, chops things. As far as the patient can pay, he can chop off anything. Over the years, he has chopped many cancers, but he has also chopped off countless normal body parts. Now, if you persuaded a patient to undergo surgery but the resection specimen turned out to be normal, you would probably blush and wonder how to explain. But not Chopper. He would just knock on the door with a radiant smile and trumpet with his baritone voice, “Congratulations, madam! There was nothing but normal tissue. It was not cancer. You don’t need to worry now.” Time and again, the patient would thank him wholeheartedly, eyes filled with tears.
Last year, a high-ranking official from the Whirlpool Galaxy travelled to Earth. He had cancers spread everywhere. No healer from his galaxy could offer any cure. Chopper was undeterred. “I can chop off your airbags and the oncologists can then take care of the smaller tumors,” he explained.
The official could not live without airbags and died shortly after the chopping procedure. Furious, a group of Whirlpoolers grabbed Chopper and planned to burn him in M51. As luck would have it, Charles Messier learned about the operation and rescued Chopper from the Whirlpoolers. That said, Chopper’s eyes were burnt by the scorching flame of the Sun. If you come across him, you may still see him wearing a pair of extra-large sunglasses.
Chopper, as you may imagine, chops things. As far as the patient can pay, he can chop off anything. Over the years, he has chopped many cancers, but he has also chopped off countless normal body parts. Now, if you persuaded a patient to undergo surgery but the resection specimen turned out to be normal, you would probably blush and wonder how to explain. But not Chopper. He would just knock on the door with a radiant smile and trumpet with his baritone voice, “Congratulations, madam! There was nothing but normal tissue. It was not cancer. You don’t need to worry now.” Time and again, the patient would thank him wholeheartedly, eyes filled with tears.
Last year, a high-ranking official from the Whirlpool Galaxy travelled to Earth. He had cancers spread everywhere. No healer from his galaxy could offer any cure. Chopper was undeterred. “I can chop off your airbags and the oncologists can then take care of the smaller tumors,” he explained.
The official could not live without airbags and died shortly after the chopping procedure. Furious, a group of Whirlpoolers grabbed Chopper and planned to burn him in M51. As luck would have it, Charles Messier learned about the operation and rescued Chopper from the Whirlpoolers. That said, Chopper’s eyes were burnt by the scorching flame of the Sun. If you come across him, you may still see him wearing a pair of extra-large sunglasses.
2 May 2013
Equality
What, then, is equality?
According to our young student, equality means rich and poor people should receive the same medical service. Allowing some patients to pay for earlier treatment is discrimination against the poor and jeopardizes their welfare. You may argue that the problem only exists when an institute practises private and public services at the same time. In a broader sense, however, unless the supply of healthcare workers is unlimited, the private market drags manpower away from the public system and affects the waiting time and service quality similarly.
Many people would object to the student’s idea of equality. It violates the freedom of choice. If people are not allowed to buy what they want, there will be limited incentives for working. As my co-interviewer said, this would be the path to communism.
Nevertheless, in the case of medical care, freedom of choice is not the only issue. Most of us would not mind the rich buying a Porsche while the sports cars are inaccessible to people less well-off. In contrast, it would be unacceptable if firefighters would only come after payment by victims. Therefore, the root of the problem is what we consider as essential care.
According to our young student, equality means rich and poor people should receive the same medical service. Allowing some patients to pay for earlier treatment is discrimination against the poor and jeopardizes their welfare. You may argue that the problem only exists when an institute practises private and public services at the same time. In a broader sense, however, unless the supply of healthcare workers is unlimited, the private market drags manpower away from the public system and affects the waiting time and service quality similarly.
Many people would object to the student’s idea of equality. It violates the freedom of choice. If people are not allowed to buy what they want, there will be limited incentives for working. As my co-interviewer said, this would be the path to communism.
Nevertheless, in the case of medical care, freedom of choice is not the only issue. Most of us would not mind the rich buying a Porsche while the sports cars are inaccessible to people less well-off. In contrast, it would be unacceptable if firefighters would only come after payment by victims. Therefore, the root of the problem is what we consider as essential care.
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