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<p class="MsoNormal">Good Evening,<o:p></o:p></p>
<p class="MsoNormal"><o:p> </o:p></p>
<p class="MsoNormal">I just wanted to follow up on a few items. First, I received a question requesting clarification on Gilbert’s Syndrome as to whether it is considered an intrahepatic process or a prehepatic process. Gilbert’s syndrome is considered an
intrahepatic process as it refers to a deficiency in the enzyme used in glucuronidation. This process occurs in the hepatocyte and therefore is considered intrahepatic. Examples of prehepatic processes that can lead to jaundice would be a resolving hematoma
vs. hemolytic anemia (before unconjugated bilirubin is taken up by the hepatocyte).
<o:p></o:p></p>
<p class="MsoNormal"><o:p> </o:p></p>
<p class="MsoNormal">Second, we talked a great deal about diseases that present with a hepatocellular pattern of injury versus diseases that present with a cholestatic pattern of injury. Diseases typically start and present with these patterns which helps
on our initial evaluation to form a differential diagnosis. However as diseases progress, and if a patient develops cirrhosis, patients can have a clinical picture of both hepatocellular and cholestatic injury. Also, in the instance of
<u>severe acute injury</u>/hepatitis with significant inflammation(acute viral hepatitis, toxin injury, shock liver, alcoholic hepatitis) there is typically a
<u>very high AST/ALT</u> with a component of cholestasis as well (these patients often present jaundiced).<o:p></o:p></p>
<p class="MsoNormal"><o:p> </o:p></p>
<p class="MsoNormal">Third, I would like to clarify on the topic of cardiology clearance. If you recall the patient we discussed during GI Inbox was a 65-year-old male with many cardiac risk factors with significant dyspnea. Given that this patient was
<u>symptomatic</u>, this patient warrants cardiology evaluation prior to sedation. Screening in asymptomatic individuals is a much more complex topic. Need for pre-operative cardiac screening would typically take factors such as overall CVD risk, functional
status, low-risk vs. high-risk procedures into consideration. For those of you that would like an additional resource, I have included the executive summary of the ACC/AHA guidelines for pre-operative cardiac management and treatment. However, if interested
I would recommend reading this over block break! <o:p></o:p></p>
<p class="MsoNormal"><o:p> </o:p></p>
<p class="MsoNormal">Lastly, I would like to highlight a few items. Screening recommendations are for asymptomatic patients. If a patient presents with symptoms, the focus shifts from screening evaluation to a diagnostic evaluation (screening guidelines are
not used for determining the timing of an evaluation in a patient who is presenting with symptoms). Also, as I mentioned demographics and risk factors are always helpful to factor in when evaluating patients or taking an exam.
<o:p></o:p></p>
<p class="MsoNormal"><o:p> </o:p></p>
<p class="MsoNormal">I wish you all good luck on your exam! Thank you so much for your attention during the GI unit.
<o:p></o:p></p>
<p class="MsoNormal"><o:p> </o:p></p>
<p class="MsoNormal">Sincerely, <o:p></o:p></p>
<p class="MsoNormal">JH<o:p></o:p></p>
<p class="MsoNormal"><o:p> </o:p></p>
<p class="MsoNormal">Jennifer Hastings, MSHS, PA-C<o:p></o:p></p>
<p class="MsoNormal">Adjunct Professor<o:p></o:p></p>
<p class="MsoNormal">Campbell University Physician Assistant Program<o:p></o:p></p>
<p class="MsoNormal">jhastings@campbell.edu<o:p></o:p></p>
<p class="MsoNormal"><o:p> </o:p></p>
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