Dear Dr Strong, I am finding all your videos extremely helpful for my studies. They are clear, concise, logical and accessible: much more so than most other medical educational material that I have found. Thank you very very much for making them - and allowing us to benefit from them for free.
Dear Dr. Eric your lectures are absolutely amazing, they are so enlightening and pragmatic. At the end of this video you mentioned that there will be videos about hepatic encephalopathy, variceal bleeding and hepatopulmonary syndrome, but I couldn't find them. I will be thankful if you tell me how to find them or if they are not yet uploaded, please tell me when will that happen. I have a huge interest in Hepatology and I am looking forward to watch it. Greetings from a med student from Macedonia.
Dr. Eric please do some video lectures on central nervous system.. specially on some disease which are poorly understood and interesting at the same time like GBS, Transverse myelitis, BSS.. Thanks in advance.
Hi, dear Eric, Thank you for sharing your knowledge unconditionally with us again. Your videos are very very helpful. You are helping many many many directly and indrectly... You will make the world more beautiful! By the way , how do you think about intra peritoneal administration of antibiotics after therapeutic paracentesis to patients with SBP due to cirrhotic ascites? Best wishes!
Chaterine Hepurn Thanks so much for your kind words! With intraperitoneal abx and SBP, surprisingly, it's not done, and to the best of my knowledge (and after a quick PubMed search), I can't find any trials about it. Intraperitoneal abx are commonly used in peritonitis secondary to peritoneal dialysis, and there is limited data about their use in secondary peritonitis (i.e. secondary to trauma or surgical catastrophe), but I can't find much of anything re: use in SBP. I suppose a diagnosis of SBP rarely seems certain before the fluid cell count comes back, and the patient would then require another paracentesis. (As opposed to secondary peritonitis, in which the diagnosis is rarely in doubt; or PD, in which the indwelling catheter makes administration after establishing the diagnosis relatively easy.) It would seems to make sense to use them in SBP. However, a loose analogy might be bladder irrigation with amphotericin for treatment of candidal UTIs, which has been shown to not be helpful, potentially harmful, and is no longer recommended.
Eric's Medical Lectures Thank you for your quick reply! Dear Eric, Actually I had a few patients with cirrhosis, refractory ascites and SBP received abx that way. It seems that helped. But cases are not enough to make any conclusion. Again, thank you so much for taking your time and hard efforts to make these wonderful videos! Wish you a very very good day !
***** I'm very sorry, but I don't know why pneumococcus is a relatively common cause of SBP in children, and a literature search didn't reveal any theories about it either.
Eric's Medical Lectures It's fine. Thanks for taking the effort though :) Oh did I mention your lectures are very informative! Greetings from Malaysia.
A question from someone very naïve in the gastroenterology arena: If you were going to aspirate the ascitic fluid for diagnostic purpose, why not perform a therapeutic paracentesis anyway so that you can improve symptom control while you’ve got a catheter in there? The only reason I can think of is that you would then have to do an albumin tap and therefore people wait to find out what the diagnostic aspirate shows before intervening. Interested to hear people’s thoughts = )
This is a very good point, and in most cases of a diagnostic tap, you would take out at least a couple of liters to improve patient symptoms. The main reason this is not always done is that a therapeutic tap is a relatively long procedure, depending on the size of the paracentesis catheter and how much intraperitoneal pressure is pushing the fluid out. A diagnostic paracentesis might take an experienced clinician 10 minutes start to finish, but removing 5L in a therapeutic paracentesis could take 30-40 min. If a physician is in the middle of a busy emergency room shift, that's an extra 20-30 minutes one might not have. But if time is not an issue, it makes sense to also remove enough fluid for symptom improvement.
Thank you sir for all the effort you put in to present very important medical subjects in a simple way. May i ask, when is life-long prophylaxis is indicated against SBP? and if so what Ax are the most recommended?
Ali Faras Did I really forget to mentioned that in the video? Argh! Thanks for pointing out the omission! Pretty much everyone agrees that lifelong prophylaxis is indicated when a patient has already had 1 prior episode of SBP. There is varied practice regarding lifelong prophylaxis in other situations, but I think it's most common to prescribe it if the total protein concentration in the ascitic fluid is
mmagdawy In terms of how much fluid can be removed for a therapeutic paracentesis, there is no absolute rule. Typically, if you are going to go through the trouble of the procedure and subject the patient to its associated risks, most clinicians remove at least 5 liters at a time, though I've seen some as high as 10L (particularly in patients who have already demonstrated no problems after increasingly higher amounts during repeat paracenteses). I've heard of patients getting even more than 10L off at a time, but I wouldn't personally recommend that. In the US, any paracentesis removing 5 or more liters is usually accompanied by giving IV albumin in order to prevent post-procedure hypotension and electrolyte abnormalities, though the benefit of this is debatable. Finally, there are some situations in which a patient may have dramatic benefit from the removal of a relatively small amount of fluid. For example, in patients who have so much fluid that their abdominal wall is literally tense (often referred to as "tense ascites"), they are at risk of developing a mild form of abdominal compartment syndrome, in which the intraperitoneal pressure is so high that it reduces the glomerular filtration pressure gradient, leading to reduced urine production and possibly acute kidney injury. When this happens, removal of just 1-2 liters may be sufficient to dramatically reduce intraperitoneal pressure, though such reduction may only last for a couple of days (i.e. it just buys time; it doesn't fix the problem)
Eric's Medical Lectures What about the effect of paracentesis of high volumes on the incidence of hepatic encephalopathy.? In my med school professors talks about that so much ...
mmagdawy I know of no such associated between high volume paracentesis and an increased incidence of hepatic encephaloapthy, and just did a quick literature search that failed to turn up one either. Please let me know if your professors cite a specific study. Theoretically, of the three major approaches to severe ascites, high volume paracentesis should be least likely to precipitate encephalopathy. TIPS is a very well established cause of encephalopathy, and preexistance of the latter is a contraindication to the former. In addition, aggressive diuresis and salt restriction leads to hyponatremia which is been shown to be associated with encephalopathy (though not necessary in a cause-effect relationship).
They are not specifically contraindicated, but they won't directly help with the infection itself. Also, SBP is a well-described trigger for hepatorenal syndrome, the onset of which can be easily confused for overdiuresis from excessive diuretics, and vice versa. So I would probably be cautious about their use in a patient who was actively being treated for SBP.
I'm very sorry, but this is a TH-cam issue that I cannot resolve from my end. Some videos just are not able to support captures for reasons which I don't understand. In the past, searching for solutions for this issue online has turned up nothing useful.
Dear Dr Strong, I am finding all your videos extremely helpful for my studies. They are clear, concise, logical and accessible: much more so than most other medical educational material that I have found. Thank you very very much for making them - and allowing us to benefit from them for free.
Professor Dr. Eric Strong, congratulations for this outstanding lecture! Best regards, Breno, Brazil.
Eric, Thanks for all of your effort and well-presented topics in internal medicine. You are truly an asset to the profession. Keep up the good work.
Dear Dr. Eric your lectures are absolutely amazing, they are so enlightening and pragmatic. At the end of this video you mentioned that there will be videos about hepatic encephalopathy, variceal bleeding and hepatopulmonary syndrome, but I couldn't find them. I will be thankful if you tell me how to find them or if they are not yet uploaded, please tell me when will that happen. I have a huge interest in Hepatology and I am looking forward to watch it. Greetings from a med student from Macedonia.
Excellent. Much appreciated by myself and my future patients.
Please why did the algorithm show "No" at 11:56 while you said "the patient has SBP"?
Thanks a lot for your effort, Dr. Eric. Your videos are perfect.
Best ever video on TH-cam 😮
Very amazing approach and easy to understand 😍
Thank you dr Eric
God bless you 🌷
its an important subject i learned alot from this vedio and i now understand this excellently explained subject
Very Helpful 👍🏻👍🏻
Strong work😜
Thank you for sharing!!!
Dr. Eric please do some video lectures on central nervous system.. specially on some disease which are poorly understood and interesting at the same time like GBS, Transverse myelitis, BSS.. Thanks in advance.
Thank you professor for the amazing and clearly explained lecture
Amazing amazing video, thank you! 🤩
Great effort
Great video! Thank you, Sir!
Great Sir....
thank you very much!
Great job
This is amazing 😭
Thank you very much Dr Strong , oh I never watch this before ? :) I learn from this , thanks very much.
Thank you sir 🙏🏼
please make a video about pulmonary complication of cirrhosis
Hi, dear Eric,
Thank you for sharing your knowledge unconditionally with us again. Your videos are very very helpful. You are helping many many many directly and indrectly... You will make the world more beautiful!
By the way , how do you think about intra peritoneal administration of antibiotics after therapeutic paracentesis to patients with SBP due to cirrhotic ascites?
Best wishes!
Chaterine Hepurn Thanks so much for your kind words!
With intraperitoneal abx and SBP, surprisingly, it's not done, and to the best of my knowledge (and after a quick PubMed search), I can't find any trials about it. Intraperitoneal abx are commonly used in peritonitis secondary to peritoneal dialysis, and there is limited data about their use in secondary peritonitis (i.e. secondary to trauma or surgical catastrophe), but I can't find much of anything re: use in SBP. I suppose a diagnosis of SBP rarely seems certain before the fluid cell count comes back, and the patient would then require another paracentesis. (As opposed to secondary peritonitis, in which the diagnosis is rarely in doubt; or PD, in which the indwelling catheter makes administration after establishing the diagnosis relatively easy.)
It would seems to make sense to use them in SBP. However, a loose analogy might be bladder irrigation with amphotericin for treatment of candidal UTIs, which has been shown to not be helpful, potentially harmful, and is no longer recommended.
Eric's Medical Lectures Thank you for your quick reply! Dear Eric,
Actually I had a few patients with cirrhosis, refractory ascites and SBP received abx that way. It seems that helped. But cases are not enough to make any conclusion.
Again, thank you so much for taking your time and hard efforts to make these wonderful videos! Wish you a very very good day !
+Eric Strong. Dear Dr, it would be great if you could explain why Streptococcus pneumoniae is the commonest organism in pediatric age group for SBP.
***** I'm very sorry, but I don't know why pneumococcus is a relatively common cause of SBP in children, and a literature search didn't reveal any theories about it either.
Eric's Medical Lectures It's fine. Thanks for taking the effort though :) Oh did I mention your lectures are very informative! Greetings from Malaysia.
What is best antibiotic?
A question from someone very naïve in the gastroenterology arena: If you were going to aspirate the ascitic fluid for diagnostic purpose, why not perform a therapeutic paracentesis anyway so that you can improve symptom control while you’ve got a catheter in there? The only reason I can think of is that you would then have to do an albumin tap and therefore people wait to find out what the diagnostic aspirate shows before intervening.
Interested to hear people’s thoughts = )
This is a very good point, and in most cases of a diagnostic tap, you would take out at least a couple of liters to improve patient symptoms. The main reason this is not always done is that a therapeutic tap is a relatively long procedure, depending on the size of the paracentesis catheter and how much intraperitoneal pressure is pushing the fluid out. A diagnostic paracentesis might take an experienced clinician 10 minutes start to finish, but removing 5L in a therapeutic paracentesis could take 30-40 min. If a physician is in the middle of a busy emergency room shift, that's an extra 20-30 minutes one might not have. But if time is not an issue, it makes sense to also remove enough fluid for symptom improvement.
Strong Medicine Thank you for your answer and the very informative video sir =)
exceptional
Thank u it is so helpful
Nice
Thank you sir for all the effort you put in to present very important medical subjects in a simple way.
May i ask, when is life-long prophylaxis is indicated against SBP? and if so what Ax are the most recommended?
Ali Faras Did I really forget to mentioned that in the video? Argh! Thanks for pointing out the omission! Pretty much everyone agrees that lifelong prophylaxis is indicated when a patient has already had 1 prior episode of SBP. There is varied practice regarding lifelong prophylaxis in other situations, but I think it's most common to prescribe it if the total protein concentration in the ascitic fluid is
Thanks a lot for the lecture Dr Eric ,What do you mean by large amounts of Ascitic fluid...??? 4 or 5 liters is the highest amount???
mmagdawy In terms of how much fluid can be removed for a therapeutic paracentesis, there is no absolute rule. Typically, if you are going to go through the trouble of the procedure and subject the patient to its associated risks, most clinicians remove at least 5 liters at a time, though I've seen some as high as 10L (particularly in patients who have already demonstrated no problems after increasingly higher amounts during repeat paracenteses). I've heard of patients getting even more than 10L off at a time, but I wouldn't personally recommend that. In the US, any paracentesis removing 5 or more liters is usually accompanied by giving IV albumin in order to prevent post-procedure hypotension and electrolyte abnormalities, though the benefit of this is debatable.
Finally, there are some situations in which a patient may have dramatic benefit from the removal of a relatively small amount of fluid. For example, in patients who have so much fluid that their abdominal wall is literally tense (often referred to as "tense ascites"), they are at risk of developing a mild form of abdominal compartment syndrome, in which the intraperitoneal pressure is so high that it reduces the glomerular filtration pressure gradient, leading to reduced urine production and possibly acute kidney injury. When this happens, removal of just 1-2 liters may be sufficient to dramatically reduce intraperitoneal pressure, though such reduction may only last for a couple of days (i.e. it just buys time; it doesn't fix the problem)
thanks a lot ..
Eric's Medical Lectures What about the effect of paracentesis of high volumes on the incidence of hepatic encephalopathy.? In my med school professors talks about that so much ...
mmagdawy I know of no such associated between high volume paracentesis and an increased incidence of hepatic encephaloapthy, and just did a quick literature search that failed to turn up one either. Please let me know if your professors cite a specific study. Theoretically, of the three major approaches to severe ascites, high volume paracentesis should be least likely to precipitate encephalopathy. TIPS is a very well established cause of encephalopathy, and preexistance of the latter is a contraindication to the former. In addition, aggressive diuresis and salt restriction leads to hyponatremia which is been shown to be associated with encephalopathy (though not necessary in a cause-effect relationship).
awesome
can you share with me this slide about SBP? thankyou very much
dear doc Eric what will we do to beta blocker if that is taking for variceal prophylaxis ......
Pllllzzz sir spontaneous bacterial peritonitis dises m nanotechnology ka kaha p use hota h vo btay
Can we use diuretics with SBP?
They are not specifically contraindicated, but they won't directly help with the infection itself. Also, SBP is a well-described trigger for hepatorenal syndrome, the onset of which can be easily confused for overdiuresis from excessive diuretics, and vice versa. So I would probably be cautious about their use in a patient who was actively being treated for SBP.
what if you have hyperthyroidism
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I'm very sorry, but this is a TH-cam issue that I cannot resolve from my end. Some videos just are not able to support captures for reasons which I don't understand. In the past, searching for solutions for this issue online has turned up nothing useful.
@@StrongMed
No problem sir , thank you anyway
Solo se leer ingles.