A Simple Guide to Liver Cirrhosis I

A Simple Guide to Liver Cirrhosis I
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What is Liver Cirrhosis?
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Liver Cirrhosis is a chronic liver disease where the normal liver tissue is replaced by bands of fibrous scar tissue separating nodules of regenerated liver cells resulting in gradual loss of liver function.

Who is at risk of getting Liver Cirrhosis?
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1.Alcohol abuse

2.Genetic causes of Biliary Obstruction such as biliary atresia

3.Hepatitis viral infection

4.Obese -fatty liver can end in liver cirrhosis

5.Exposure to excessive chemicals(factory) or medications(eg statins)

What are the causes of Liver Cirrhosis?
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The main causes of Liver Cirrhosis are:

1.chronic alcoholism:

Alcohol tends to block the normal metabolism of protein, fats, and carbohydrates leaving toxic material behind which can injure the liver and ends in liver cirrhosis.

2.hepatitis C virus infection:

Chronic hepatitis c viral infection causes inflammation of the liver which over the years can damage the liver and lead to cirrhosis.

3.Primary biliary and secondary cirrhosis:

Primary biliary cirrhosis cause is unknown.
Secondary biliary cirrhosis results from chronic obstruction of the biliary tract resulting in chronic inflammation of the liver cells and fibrosis of the liver.
Nodular regeneration of the liver cells occurs subsequently.
Obstruction to the bile ducts can be caused by:
Cholecystitis
Gallstones
Biliary cholangitis

4.Others:
Metabolic diseases:
Hemachromatosis
Wilson Disease

Parasitic Disease:
Schistosomiasis

Cardiac cirrhosis
Liver congestion results from right sided heart failure

Autoimmune Diseases:
Autoimmune hepatitis

Exposure to chemicals and medications

Glycogen storage disease


What are the Symptoms and signs of Liver Cirrhosis?
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Common symptoms of Liver Cirrhosis are:

1.Anorexia

2.fatigue and weakness

3.Gradual onset of jaundice(Yellow discoloring of the skin, eye, and mucus membranes due to increased bilirubin)

4.weight loss.

5.Fetor hepaticus - odor in breath due to increased dimethyl sulfide

Signs:

1.Spider nevi- central arteriole surrounded by many smaller vessels due to an increase in estradiol .

2.Palmar erythema -redness of the palms due to impaired sex hormone metabolism.

3.Liver size. Can be enlarged, normal, or shrunken.

4.Splenomegaly - Due to congestion of the spleen as a result of portal hypertension.

5.Ascites . Accumulation of fluid in the peritoneal cavity

6.hydrocele and penile flomation (swelling of the penile shaft)

7.Hypogonadism - impotence, infertility, poor sexual drive, and testicular atrophy due to primary gonadal injury or suppression of hypothalamic or pituitary function.

8.Gynecomastia - This is due to increased estradiol in male patients.

9.Hypertrophic osteoarthropathy - Chronic proliferative periostitis of the ribs can be very painful.

10.Dupuytren's contracture -palmar fascia tightens to cause flexion deformities of the fingers.

11.Nail changes:

Muehrcke's nails - paired horizontal bands due to hypoalbuminemia
Terry's nails - proximal 2/3 of the nail appears white with distal one-third red due to hypoalbuminemia
Clubbing - angle between the nail plate and proximal nail fold > 180 degrees

12.Caput medusa -In portal hypertension, the umbilical vein may be distended.

13.Cruveilhier-Baumgarten murmur. Venous blood flow hum heard in epigastric region due to portal hypertension

14.Asterixis - Bilateral asynchronous flapping of outstretched, dorsiflexed hands seen in patients with hepatic encephalopathy.


How is the diagnosis of Liver Cirrhosis made?
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1. liver biopsy will confirm liver cirrhosis through a percutaneous laparoscopic , or fine-needle approach but may not necessary if the clinical, laboratory, and radiologic data suggests cirrhosis.

there is a small but significant risk to liver biopsy, and cirrhosis itself predisposes for complications due to liver biopsy

2.Lab findings
The following findings are typical in cirrhosis:

a.Aminotransferases - AST and ALT are moderately elevated, with AST > ALT.
b.Alkaline phosphatase - usually slightly elevated.
c.GGT - correlates with AP levels- much higher in chronic liver disease from alcohol.
d.Bilirubin - may elevate as cirrhosis progresses.
e.Albumin - levels fall as the synthetic function of the liver declines with worsening cirrhosis
f.Prothrombin time - increases since the liver synthesizes clotting factors.
g.Globulins - increased due to shunting of bacterial antigens away from the liver to lymphoid tissue.
h.Serum sodium is low due to inability to excrete free water resulting from high levels of ADH and aldosterone
i.Thrombocytopenia - due to both congestive splenomegaly as well as decreased thrombopoietin from the liver. Platelet count is rarely < 50,000/mL.
j.Leukopenia and neutropenia - due to splenomegaly with splenic margination.
k.Coagulation defects - the liver produces most of the coagulation factors and thus coagulopathy correlates with worsening liver disease.

l.Serology for hepatitis viruses, autoantibodies (ANA or Anti-nuclear antibody, anti-smooth muscle, anti-mitochondria n.antibody, anti-LKM)
n.Ferritin and transferrin saturation (markers of iron overload),
o.copper and ceruloplasmin Ceruloplasmin> (markers of copper overload)
p.Immunoglobulin levels (IgG, IgM, IgA) - high

To determine various causes
p.Cholesterol and glucose
r.Alpha 1-antitrypsin

3.Imaging
Ultrasound is used to assess the degree of cirrhosis:

a.small and nodular liver in advanced cirrhosis
b.increased echogenicity with irregular appearing areas.

Ultrasound may also screen for
a.hepatocellular carcinoma
b.portal hypertension
c.Budd-Chiari syndrome by checking the blood flow in the hepatic vein

FibroScan (transient elastography) uses elastic waves to assess liver stiffness which can grade the severity of cirrhosis.

Abdominal CT and liver and bile duct MRI - may show the the degree of liver cirrhosis

4.Imaging of the bile ducts, such as
ERCP Endoscopic_retrograde_cholangiopancreatography or
MRCP Magnetic_resonance_cholangiopancreatography (MRI of biliary tract and pancreas)
can show abnormalities in the liver

5.Endoscopy
Gastroscopy is performed in patients with liver cirrhosis to exclude the possibility of esophageal varices.

A Simple Guide to Cutaneous Larva migrans

A Simple Guide to Cutaneous Larva migrans
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What is Cutaneous Larva migrans?
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Cutaneous Larva migrans is a common skin condition which appears as a red snake-like itchy rash caused by penetration and subsequent migration of larvae of various worm parasites.

The condition is benign and self-limited.

It is most commonly found in tropical countries.

Who is at risk from Cutaneous Larva migrans?
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1.People of all ages are affected but it is more common in children

2.It is more common in hot tropical climates

3.Certain occupations that involve contact with warm, moist, sandy soil:
Farmer
Gardener

4.Certain hobbies that involve contact with warm, moist, sandy soil:
Tropical climate travellers
Barefoot beach goers
Children building sandcastles

What are the causes of Cutaneous Larva migrans?
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The larvae usually hatch from eggs laid in animal faeces and then penetrate through the intact skin of the children or adults.

After shedding their covering, they begin migrating in the epidermis.

Because they are unable to penetrate through the dermis, the disease remains limited to the skin of humans.

THE MOST COMMON PARASITES ARE:
DOG HOOKWORMS:
Ancylostoma braziliense
Ancylostoma caninum
Uncinaria stenocephala

Rarer causes are:
Ancylostoma tubaeforme (cat hookworm)
Necator americanus (human hookworm)
Ancylostoma duodenale

What are Signs and symptoms of Cutaneous Larva migrans?
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Symptoms:

1.prickling sensation at the site within 30 minutes of larva penetration of the skin

2.Intense itchiness

3.Red linear lesions that moves

4.walking barefoot on the beach in a tropical location

Signs:

1.Itchy, red, raised papules or vesicles

2.snakelike, slightly elevated, red tunnels that are 2-3mm wide and 3-4 cm long from the penetration site

3.Vesicles with clear fluid

4.Tract movement of 1-2 cm/day

5.peripheral eosinophilia (Loeffler syndrome),

6.migratory lung infiltrates,

7.Lesions are typically present on the distal lower extremities,
the dorsa of the feet and the interdigital spaces of the toes,
anogenital region,
the buttocks,
the hands, and
the knees.

How is the diagnosis of Cutaneous Larva migrans made?
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Diagnosis is mostly based on the
1.classic clinical appearance of the eruption.

2.peripheral eosinophilia on a Complete Blood Count

3.increased IgE levels on total serum immunoglobulin determinations.

4. skin biopsy taken just before leading edge of a tract may show
a larva (periodic acid-Schiff positive) in a
suprabasalar burrow,
basal layer tracts,
spongiosis
intraepidermal vesicles,
necrotic keratinocytes,
an epidermal and upper dermal chronic inflammatory infiltrate with many eosinophils.

What are the complications of Cutaneous Larva migrans?
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1. secondary bacterial infection, usually with Streptococcus pyogenes, may lead to cellulitis.

2. Allergic reactions may occur.

What is the treatment of Cutaneous Larva migrans?
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The condition is usually self-limiting.
The intense itchiness and risk for infection may require treatment.

Invasive treatment:
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1.liquid nitrogen cryotherapy for progressive end of larval burrow.

2.electrocautery

Medication:
----------------

1.Thiabendazole
Thiabendazole is the best medication
Topical application is used for early, localized lesions.
The oral route is preferred for widespread lesions or unsuccessful topical treatment.

2.Mebendazole (Vermox)
Broad-spectrum anthelmintic that inhibits microtubule assembly and irreversibly blocks glucose uptake, thereby depleting the parasites' glycogen stores.

Other effective treatments include
3.albendazole,
4.ivermectin.

In most cases there is decreased itchiness within 24-48 hours and lesions resolve in 1 week.

5.Antibiotics are given if there are secondary bacterial superinfections.

6.Antihistamines are given for severe itchiness

What is the prognosis of Cutaneous Larva migrans ?
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The prognosis is excellent.

This is a self-limiting disease.

Humans are accidental hosts and the larva usually dies within 4-8 weeks.

The lesions usually will disappear within 8 weeks to 1 year depending on complications.

What are the Preventive measures taken for Cutaneous Larva migrans ?
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Travellers to tropical regions and pet owners should be made aware of this condition.

Prevention is by avoiding direct skin contact with possible faecally contaminated soil.

A Simple Guide to Folliculitis

A Simple Guide to Folliculitis
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What is Folliculitis?
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Folliculitis is a bacterial infection of the skin hair follicle.


Who is at risk from Folliculitis?
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People of all ages are affected .

It is more common in diabetes and people with low immune system.


What are the causes of Folliculitis?
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1.The cause is infection of bacteria such as Staphylococcus aureus.

2.Poor skin hygiene

3.Skin damaged by eczema and dermatitis

4.Nasal transport of Staphylococcus aureus.

5.May complicate diabetes and low immune system patients like leukemia.


What are Signs and symptoms of Folliculitis?
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Symptoms:

1.Occurs at root of a hair follicle

2.superficial pustule or nodule

3.May become chronic at beard area.

4.May be painful


How is the diagnosis of Folliculitis made?
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1.pustule at root of hair.

2.Skin scraping for microscopic examination, culture and sensitivity.

3.Blood count.



What are the complications of Folliculitis?
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1.Fungal infection

2.furuncle or carbuncle which are bigger and deeper areas of infection.


What is the treatment of Folliculitis?
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A. Skin hygiene
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1. clean skin with antiseptic.

2. avoid scratching the skin

3. avoid plaster and poultices

4. cover with gauze after skin injury


B. Medicines:
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1. topical antibacterials such as bacitracin, neomycin, gentamycin, tetracycline creams

2. Oral Antibiotics may be given if necessary.

3. Complicated conditions such as carbuncles may require surgical debridement.


What is the prognosis of Folliculitis ?
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Generally good to excellent but may recur.

Prompt treatment is important to prevent complication


What are the Preventive measures taken for Folliculitis?
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1.Good skin hygiene

2.Healthy lifestyle with balanced diet and adequate sleep.

3.Avoid scratching of skin

4.Use clean razors for shaving

5.Avoid plasters and poultices.

A Simple Guide to Prickly Heat

A Simple Guide to Prickly Heat
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What is Prickly Heat?
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Prickly Heat(also known as miliaria) is a common non contagious disease which appears as acute itchy red rash on the body due to retained sweat.


Who is at risk from Prickly Heat?
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People of all ages are affected but it is more common in children and infants due to their underdeveloped sweat glands.

It is more common in hot and humid conditions.


What are the types of Prickly Heat?
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I.Miliaria crystallina-
minute superficial vesicular lesions that normally do not cause any symptoms

2.Miliaria rubra -
deeper layer inflammatory lesions causing the typical appearance of redness (hence rubra) and larger blister-like lesions.

There is intense itching with a lack of sweating to affected areas.

This is the most common form of prickly heat.

3.Miliaria profunda-
the most severe form of miliaria due to the rapid spread and severe burning sensations.

The obstruction is deep in the structure of the sweat gland resulting in the sweat to leak between the superficial and deep layers of the skin.

The rash occurs within hours of an activity provoking sweating and disappear within hours when the stimulus for the sweating is removed.

The risk of heat exhaustion is higher.


What are the causes of Prickly Heat?
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The cause is the result of the keratin or dead skin cells or bacteria such as Staphylococcus epidermidis of the skin blocking the sweat ducts.

The occluded sweat ducts ruptures when sweating occur and the sweat form an intraepidermal vesicle which leads to irritation(prickly sensation) and itchiness.

Secondary infection may occurs from invasion of staphalococcus.


What are Signs and symptoms of Prickly Heat?
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Symptoms:

1.Occurs in humid hot weather

2.Small red papulovesicular rashes

3.Occurs on the face, neck, under the breasts, trunk, under the scrotum, skin folds, behind knee and antecubital fossa.

4.Usually very itchy

5.Rash usually presents with prickly sensation


How is the diagnosis of Prickly Heat made?
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1.Symptoms and signs of small rashes occuring in hot humid condition with itchiness and prickly sensation

2.Skin scraping for microscopic examination.


What are the complications of Prickly Heat?
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1.Fungal infection

2.bacterial infection


What is the treatment of Prickly Heat?
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A. Cool Environment
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1. air-conditioned environment

2. avoid heat and sweat-inducing activities

3. avoid occlusive clothing,

4. take frequent cool showers.

B. Medicines:
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1. topical antibacterials may reduce the symptoms in miliaria rubra

2. anti-itch preparations such as calamine or menthol preparations

3. topical steroid creams,

4. Avoid oil based preparations because they increase blockage to the sweat glands.

5. Oral Antibiotics may be given if there is secondary infection.

6. Oral antihistamines may be given if itch is troublesome.

7. VItamin C or A in high dosages have not been found to be effective


What is the prognosis of Prickly Heat ?
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Generally good to excellent but may recur.

Environmental factors like humidty and heat should be avoided.


What are the Preventive measures taken for Prickly Heat ?
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1.Good skin hygiene

2.Healthy lifestyle with balanced diet and adequate sleep.

3.Wear light clothing

4.Reduce sweating (use air conditioner)

5.Frequent showers should help

6.Avoid heat and humidity.

A Simple Guide to Osteogenesis Imperfecta

A Simple Guide to Osteogenesis Imperfecta
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What is Osteogenesis Imperfecta(also known as Brittle Bones)?
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Osteogenesis imperfecta (OI) is an inherited disorder of the connective tissue resulting in imperfect bone formation and hence causing fractures in childhood.
It also causes fractures in adults.

Who is at risk of Osteogenesis Imperfecta?
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Osteogenesis Imperfecta is a congenital condition affecting 2 forms of genetic disorder:
1.autosomal dominant - usually milder with frequent fractures

2.autosomal recessive - usually more severe and can lead to early death

Therefore there is always a family history of fractures of children in the family.

usually resulting from abnormalities of the genes that control the production of a protein called ; it has nothing to do with the calcium part of bone, which is what shows up on X-rays


What causes Osteogenesis Imperfecta?
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Osteogenesis Imperfecta is a condition resulting from impaired maturation of the collagen fibres or synthesis of abnormal collagen.

Collagen is the main protein in bone and is necessary for the bone to form strong bone matrix.
The abnormal collagen results in soft fragile bones, ligamentous laxity and thin sclera.

In the autosomal dominant form of Osteogenesis Imperfecta, the condition can be passed from one generation to the next.

Sometime the cause is a new genetic mutation which results in the Osteogenesis Imperfecta.
There is no previous history of Osteogenesis Imperfecta.
This has been seen in IVF of frozen egg from mothers trying for a pregnancy.


What are the symptoms of Osteogenesis Imperfecta?
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Symptoms:
---------------

1.fractures is the most common symptom especially in newborns.
Multiple fractures may occur easily in the newborns and pose a danger to life.
As the child grow older the risk of fractures decreases especially after puberty.

2.lax joints

3.eyes conjunctiva(white)may be blue or grey.

4.teeth may be discoloured and fragile.

5.increased liability to bruising due to the abnormal collagen in the lining of small blood vessels.

6.Deafness is due to problems in the small bones in the middle ear which may be fractured or deformed so that sound waves cannot be transmitted easily to the inner ear

7.Hernias are due to poor formation of collagen fibres or abnormal collagen in the muscles.

8.Excessive sweating or intolerance of heat - the cause of this is unknown.

9.Dwarfism and structural abnormalities may occur due to basic defect and frequent fractures

10.Mental development is not affected

How do you made the diagnosis of Osteogenesis Imperfecta?
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Diagnosis of Osteogenesis Imperfecta is often based on
1. history and pattern of fractures

2. blue or gray whites of the eyes.

3.X-rays in severe cases -shows previous fractures and deformities
The bones may appear demineralised .

4.wormian bones are additional small bones seen in the sutures between the scalp bones.
They occur in 50% cases of Osteogenesis Imperfecta.

5.Specialised test for diagnosis of Osteogenesis Imperfecta involve taking a small piece of skin, culturing the cells and chemically examining the collagen produced.

6.Another specialized test uses a blood sample to search for mutations of the genes coding for the collagen of bone.


What are the complications of Osteogenesis Imperfecta?
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The complications of Osteogenesis Imperfecta are:

1. multiple frequent fractures of the bone,

2. deformities of the bone and body

3. death in newborns from multiple fractures


What is the treatment of Osteogenesis Imperfecta?
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1.Good treatment of fractures to make sure that the bones healed without deformities.
Immobilization of fractures can lead to the loss of bone so early mobilization of the patient is important.

2.Surgical use of fixed or telescopic metal rods inserted into the shafts of bones can prevent appreciable deformity.

3.occupational therapy is important in preventing falls especially with handrails and other adaptation to the home.

4.no drug treatment including growth hormone have been effective.
Various bisphosphonate drugs trials are in progress.
There has encouraging evidence of their effectiveness in some patients.

5.Women with Osteogenesis Imperfecta may try Hormone Replacement Therapy(HRT) at menopause since HRT has been know to improve the bone structure and also prevent heart attacks.
However there is a very small risk of breast cancer.

In the case of Osteogenesis Imperfecta ,the advantages of HRT may be greater than the disadvantages as the chances of fractures is higher after the menopause.

6.Stopping smoking is important because smoking diminishes the bone by up to 5 per cent, thus increasing the risk of fractures.


What is the prognosis of Osteogenesis Imperfecta?
----------------------------------------

Prognosis depends on the severity of Osteogenesis Imperfecta.

In very severe cases, death within several years

In less severe cases, multiple and frequent fractures may occur followed by deformities.

A Simple Guide to Gynecomastia

A Simple Guide to Gynecomastia
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What is Gynecomastia?
----------------------------


Gynecomastia is unilateral or bilateral enlargement in the glandular tissue of the breast in males.


What causes Gynecomastia?
---------------------------------


The causes of gynecomastia is not completely clear.

It is believed to be caused by an imbalance of sex hormones especially during puberty.

A.Hormonal:
----------------------

1.In male babies the painless swelling of the breast may occur due to the effects of the mother's female hormones.

The swelling usually subsides after a few weeks.

2.At Puberty for boys the development of breasts is due to the increased ratio of free estradiol to free testesterone.

In most cases the breasts may disappear after 1 year.

3.Some cases of Gynecomastia may be due to ingestion of female hormones injected into chicken and ducks

B.Genetic
---------------------

Some cases of male hypogonadism causing reduced testosterone.

C.Liver cirrhosis
---------------------

Failure of metabolism of circulating estrogens can increase the female hormones in the adults and cause Gynecomastia

D.Medications:
---------------------
a.Spironolactone

b.digoxin

c.cimetidine

d.maxolon

E.Tumors
----------------
Testicular or Pituitary Tumors may cause increased estrogen and reduced testesterone and hence increase the production of breasts.


What are the symptoms of Gynecomastia?
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The Symptoms of Gynecomastia are:

1.Pain usually present in all cases except in babies

2.swelling of the breasts or the nipple area in males

Signs:

1.redness of the breast

2.swelling of the breast tissue

3.Local tenderness of swollen area


How is diagnosis of Gynecomastia confirmed?
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1. clinical features

2. Endocrine blood tests including HCG levels

3. Liver function tests

4.Ultrasound scan of the breasts


What is the treatment of Gynecomastia?
------------------------------------


1.treat underlying cause

2.Medications causing Gynecomastia should be stopped.

3.cosmetic surgery-liposuction, gland excision, reduction mammoplasty,

4.Tamoxifen if necessary

5.Radiation therapy may prevent gynecomastia in patients with prostate cancer prior to estrogen therapy.


What is the Prognosis of Gynecomastia?
------------------------------------


Most cases has good prognosis.

Aldolescent cases usually regress spontaneously.

A Simple Guide to Intermittent Claudication

A Simple Guide to Intermittent claudication
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What are Intermittent claudication?
---------------------------------------------
Intermittent claudication is a symptom of ischemic muscle pain usually in the calf muscles due to inadequate blood supply during exercise.
It is usually relieved by rest.


Who is at risk of Intermittent claudication?
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1.Age older than 65 years

2.men older than 50 years affected more than women.

3.smoking



What are the causes of Intermittent claudication?
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The causes of intermittent claudication are:

1.vascular intermittent claudication caused by peripheral arterial disease(atherosclerosis)- most common cause

2.Neurogenic intermittent claudication caused by spinal canal stenosis.



What are the symptoms of Intermittent claudication?
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The symptoms and signs are:

1.Pain in the leg especially when walking a certain distance, disappear after rest, recur again after walking

2.Paraesthesia or numbness of the leg

3.Decrease in Pulse in the leg arteries(dorsalis pedis or posterior tibial arteries)

4.Decreased in temperature due to poorer blood flow

5.Pallor of the skin of leg when leg is raised upwards to 60 degrees

6.Redness of the skin when limb is placed downwards

7.Cyanosis if blood supply to the leg is compromised

8.Atrophic changes like loss of hair

9.Bruits may be heard where the arteries are narrowed

10.Paralysis of leg if condition worsen


What are the investigations needed in assessment of Intermittent claudication?
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The type, size, location and depth of the arterial narrowing in the legs can be determined:

1.Ultrasound (non-invasive)

2.Arteriography where a dye is injected into the artery to determine the areas of narrowing.

What is the treatment for Intermittent claudication?
-------------------------------------------

In patients who smoke, smoking cessation is the most effective treatment. Exercise can improve symptoms as do Surgery is only indicated in severe cases with limb-threatening ischemia or lifestyle-limiting claudication. The vascular surgeon will perform an . Low molecular weight heparin (LMWH), oral anticoagulants (warfarin), vitamin E or chelation therapy is not effective.


A. Healthy lifestyle
--------------------------
1. Stop smoking in smokers.

2. Reduce weight in the obese

3. Exercise to improve blood flow can improve symptoms

4. Foot hygiene and appropriate chiropody

B.Medical treatment:
-------------------------
medication to control the

1.lipid profile - reduction of fats will reduce arteriosclerosis eg. statins

2.diabetes - reduction of blood sugar to normal reduce the risk of diabetic arteriosclerosis

3.hypertension - hypertensive drugs has been found particularly useful in the treatmeent of hypertension and intermittent claudication:

Angiotensin converting enzyme (ACE) inhibitors,'
beta-blockers,

4.blood clotting
antiplatelet agents (ASA and clopidogrel),

5.vasodilators
pentoxifylline
cilostazol ( PDE3 inhibitor)

C. Surgical treatment:
---------------------------

1.endarterectomy of leg arteries

2.arterial bypass of localised areas of obstruction

3.Sympathectomy may help in some resistant cases.


What is the prognosis for Intermittent claudication?
------------------------------------------------------

If treated early, prognosis is fair.

Surgical treatment is only needed if progressive gangrene develops.


How can Intermittent claudication be prevented?
-----------------------------------------------------

1.Stop smoking

2.Reduce weight

3.Exercise

4.Aviod prolonged walking

5.Put your feet up when sitting

A Simple Guide To Atrial Fibrillation II

A Simple Guide To Atrial Fibrillation II
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What is the Complications of Atrial Fibrillation?
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1.fibrosis of the atria

2.Enlarged atria and heart

3.Thrombosis to the brain(stroke),
intestines(ischemia),
fingers and toe(ischemia or gangrene)


What is the Treatment of Atrial Fibrillation?
------------------------------------------------------

The treatment of atrial fibrillation is aimed at

1.regulating the heart beat and rhythm- digoxin, dilatrend, betablockers

2.preventing blood clots to be thrown out in the blood stream -anticoagulants

3.In cases of uncontrolled tachycardia, immediate cardioversion may be done.

Regulating the heart beat:
----------------------------
a.rate control

Rate control is by drugs to reduce the heart rate to 60 to 100 bpm without changing to a regular rhythm.

The medications work by blocking the AV node reducing the electrical impulses to the ventricles.

1.Beta blockers such as metoprolol, atenolol, bisoprolol

2.Cardiac glycosides ( digoxin)

3.Calcium channel blockers (i.e. diltiazem or verapamil)

4.amiodarone has AV node blocking effects which can be used when other agents are contraindicated (eg.hypotension).

b.rhythm control

Rhythm control work to restore the regular heart rhythm and maintain it with drugs.

The anti-arrhythmic medications makes the heart tissue less excitable.
These medications are often used in concert with electrical cardioversion.

Prevention of blood clots in blood stream:
--------------------------------------------

Anticoagulation with drugs as below reduce the risk of blood clots being thrown out from the heart and blocking the passage of blood in the arteries of the heart or brain

1.aspirin

2.clopidogrel in those who are allergic to aspirin

3.warfarin or similar drugs.

4.heparin intravenously prevents blood clotting in urgent cases.

Cardioversion
---------------------
Cardioversion is the conversion of an abnormal heartbeat to a normal heartbeat using electrical or chemical means

1.Electrical cardioversion restores the heart rhythm by appying a DC electrical shock to the heart.

2.Chemical cardioversion uses medicine such as amiodarone, dronedarone, procainamide, ibutilide, propafenone or flecainide.

Cardioversion should not be done unless adequate anticoagulation has been given to patients for 48 hours.

There is a relapse rate of 1% following cardioversion.

3.Catheter ablation
It is possible to destroy the bundle of cells connecting the upper and lower chambers of the heart - the atrioventricular node - which regulates heart rate, and to implant a pacemaker Another method involves ablating groups of cells near the pulmonary veins where atrial fibrillation is thought to originate.This method do not need a pacemaker.

4. Radiofrequency ablation uses radiofrequency energy to remove abnormal electrical pathways in heart tissue.

5. laser, cryothermy and high intensity ultrasound has been use to eliminate the responsible heart tissue causing the irregular heart beats.

Surgical Maze procedure
----------------------------
A series of incisions is made in the atriain a maze-like pattern.
This block abnormal electrical circuits that AF requires.

Minimaze surgery is a minimally invasive cardiac surgery that do not require a median sternotomy or cardiopulmonary bypass.

Laser, cryothermy, radiofrequency, or acoustic energy are used to destroy atrial tissue near the pulmonary veins and and other ablations to mimic the maze.

What is the prognosis of Atrial Fibrillation?
---------------------------------------------------

Most cases of patients treated with rate control and cardioversion with ablation has excellent prognosis, usually better than those with rhthym control.

Recurrence may recur especially if there is an underlying condition which cannot be cured.

What are the prevention measures for Atrial Fibrillation?
--------------------------------------------------------------

Rest and a healthy lifestyle may help to prevent an onset or recurrence of atrial fibrillation.

Avoid stress and anxiety.