Contributor: Aaron Lessen, MD

Educational Pearls:

• Colchicine is most commonly used for the prevention and treatment of gout

• • There is research investigating the anti-inflammatory and cardioprotective effects of colchicine

• This drug has a narrow therapeutic index: a small margin between effective dose and toxic dose

• Colchicine overdoses can be unintentional or intentional and are associated with poor outcomes

• • Phase 1: 10 - 24 hours after ingestion

  • • Patient looks well but may have mild symptoms mimicking gastroenteritis

  • Phase 2: 24 hours - 7 days after ingestion

  • • Multiple organ dysfunction syndrome (MODS)

  • Phase 3: recovery is usually within a few weeks of ingestion

• Treatment for colchicine overdose

• • Treat early and aggressively

  • • Gastrointestinal decontamination with activated charcoal and orogastric lavage

    • Dialysis and ECMO for MODS treatment

References

1. Finkelstein Y, Aks SE, Hutson JR, Juurlink DN, Nguyen P, Dubnov-Raz G, Pollak U, Koren G, Bentur Y. Colchicine poisoning: the dark side of an ancient drug. Clin Toxicol (Phila). 2010 Jun;48(5):407-14. doi: 10.3109/15563650.2010.495348. PMID: 20586571.

2. Gasparyan AY, Ayvazyan L, Yessirkepov M, Kitas GD. Colchicine as an anti-inflammatory and cardioprotective agent. Expert Opin Drug Metab Toxicol. 2015;11(11):1781-94. doi: 10.1517/17425255.2015.1076391. Epub 2015 Aug 4. PMID: 26239119.

Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3

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Contributor: Travis Barlock, MD

Educational Pearls:

What is Portal Vein Thrombosis?

• The formation of a blood clot within the portal vein, which carries blood from the gastrointestinal tract, pancreas, and spleen to the liver

• Not only can this cause problems downstream in the liver, but the backup of venous blood can cause ischemia in the bowels

How does it present?

• Similar to acute mesenteric ischemia: Sudden onset of abdominal pain, nausea, vomiting, and fever

How is it diagnosed?

• Abdominal CT or MRI with contrast

What causes it?

• Cirrhosis

• Coagulopathy (Factor V Leiden mutation, Prothrombin gene mutation, Antiphospholipid syndrome, Protein C, protein S, antithrombin III deficiency, etc.)

• Oral Contraceptive Pills (OCPs)

• Cancer such as hepatocellular carcinoma

How is it treated?

• Aggressive fluid resuscitation

• Antibiotics. Be sure to cover enteric gram-negative bacteria and anaerobes

• Heparin, same dosing as a bolus for a DVT

• Endovascular treatment, such as a thrombectomy with IR

• Surgical evaluation if there has been tissue death in the mesentery

References

• Hilscher, M. B., Wysokinski, W. E., Andrews, J. C., Simonetto, D. A., Law, R. J., & Kamath, P. S. (2024). Portal Vein Thrombosis in the Setting of Cirrhosis: Evaluation and Management Strategies. Gastroenterology, 167(4), 664–672. https://doi.org/10.1053/j.gastro.2024.05.017

• Intagliata, N. M., Caldwell, S. H., & Tripodi, A. (2019). Diagnosis, Development, and Treatment of Portal Vein Thrombosis in Patients With and Without Cirrhosis. Gastroenterology, 156(6), 1582–1599.e1. https://doi.org/10.1053/j.gastro.2019.01.265

• Ju, C., Li, X., Gadani, S., Kapoor, B., & Partovi, S. (2022). Portal Vein Thrombosis: Diagnosis and Endovascular Management. Pfortaderthrombose: Diagnose und endovaskuläres Management. RoFo : Fortschritte auf dem Gebiete der Rontgenstrahlen und der Nuklearmedizin, 194(2), 169–180. https://doi.org/10.1055/a-1642-0990

Summarized by Jeffrey Olson MS3 | Edited by Jorge Chalit, OMS3

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Contributor: Jorge Chalit-Hernandez, OMS3

Educational Pearls:

• Acute mountain sickness (AMS) is the term given to what is otherwise colloquially known as altitude sickness

• High altitude cerebral edema (HACE) is a severe form of AMS marked by encephalopathic changes

• Symptoms begin at elevations as low as 6500 feet above sea level for people who ascend rapidly

• • May develop more severe symptoms at higher altitudes

• The pathophysiology involves cerebral vasodilation

• • Occurs in everyone ascending to high altitudes but is more pronounces in those that develop symptoms

  • The reduced partial pressure of oxygen induces hypoxic vasodilation in the brain, which results in edema and, ultimately, HACE in some patients

• Symptomatic presentation

• • Headache, nausea, and sleeping difficulties occur within 2-24 hours of arrival at altitude

  • HACE may occur between 12-72 hours after AMS and presents with ataxia, confusion, irritability, and ultimately results in coma if left untreated

• Clinical presentation may be mistaken for simple exhaustion, so clinicians should maintain a high index of suspicion

• • Notably, if symptoms occur more than 2 days after arrival at altitude, clinicians should seek an alternative diagnosis but maintain AMS/HACE on the differential

• Treatment and management

• • AMS

  • • Adjunctive oxygen and descent to lower altitude

    • Acetazolamide is used as a preventive measure but is not helpful in acute treatment

    • +/- dexamethasone

  • HACE

  • • Patients with HACE should receive dexamethasone to help reduce cerebral edema

    • Immediate descent to a lower altitude

References

1. Burtscher M, Wille M, Menz V, Faulhaber M, Gatterer H. Symptom progression in acute mountain sickness during a 12-hour exposure to normobaric hypoxia equivalent to 4500 m. High Alt Med Biol. 2014;15(4):446-451. doi:10.1089/ham.2014.1039

2. Levine BD, Yoshimura K, Kobayashi T, Fukushima M, Shibamoto T, Ueda G. Dexamethasone in the treatment of acute mountain sickness. N Engl J Med. 1989;321(25):1707-1713. doi:10.1056/NEJM198912213212504

3. Luks AM, Beidleman BA, Freer L, et al. Wilderness Medical Society Clinical Practice Guidelines for the Prevention, Diagnosis, and Treatment of Acute Altitude Illness: 2024 Update. Wilderness Environ Med. 2024;35(1_suppl):2S-19S. doi:10.1016/j.wem.2023.05.013

Summarized & Edited by Jorge Chalit, OMS3

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