#271 TFTC #4: PAD, Abdominal Pain, Iron Deficiency in CKD, and Acute Diarrhea

April 28, 2021 | By Matthew Watto, MD

Recap our top pearls from recent shows on peripheral arterial disease (PAD), Abdominal Pain, Iron Deficiency in CKD, and Acute Diarrhea. It’s Tales from the Curbside (TFTC)!, our monthly series providing a rapid review of recent Curbsiders episodes for your spaced learning.

Note: No CME for this mini-episode but visit curbsiders.vcuhealth.org to claim credit for #260 PAD, #263 Iron CKD, and #266 Acute Diarrhea. CME is not available for #261-262 Abdominal Pain

Credits

• Written, Produced, and Hosted by: Matthew Watto MD, FACP; Paul Williams MD, FACP  
• Infographics by: Beth Garbitelli and Edison Jyang
• Cover Art: Edison Jyang
• Editor: Matthew Watto MD (written materials); Clair Morgan of nodderly.com

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Show Segments

• Intro, disclaimer
• Peripheral Arterial Disease (Dx and Management)
• Abdominal Pain and the Abdominal Exam
• Iron deficiency and Anemia in CKD
• Acute Diarrhea
• Outro

Tales from the Curbside Top Pearls

Click the links below for complete show notes.

Ep. #260 – PAD with Dr. Vlad Lakhter 

produced by Paul Williams with graphic by Edison Jyang

Pearl – In symptomatic PAD decide whether the patient has claudication or critical limb ischemia. The latter requires revascularization. Claudication can be treated with high dose statin, an antiplatelet agent, a home exercise program, and aggressive risk factor modification (e.g. smoking cessation, and control of HTN and DM).

Pearl – The cleverly named CLEVER trial found that a supervised exercise program (3x/wk for 12 wks) was just as effective as revascularization for patients with claudication from aortoiliac disease. In lieu of a structured program, patients can be instructed to walk for 30-40 minutes, walking until claudication symptoms occur, and then resting until symptoms resolve (Dr. Lahkter’s expert opinion). 

Pearl – Consider exercise ABIs (to “unmask” disease) in the patient with a normal ankle-brachial index (ABIs) despite a  high clinical suspicion for PAD. The addition of pulse volume recording can help determine the level of pathology. You don’t need angiography unless you’re planning intervention.

Ep. #261 and 262 Abdominal Pain 

produced by Sam Masur with graphics by Beth Garbitelli

Pearl – The abdominal exam can help diagnose an acute abdomen. Check for rigidity and tenderness to percussion. Unfortunately, these aren’t great tests with +LR 3.6 and 2.4, respectively. You need to practice and feel a lot of normals to hone your skill. 

Pearl – The physical exam in isolation is not great.  It’s not going to yield you a specific diagnosis in the absence of clinical context, and a lot of the historically taught exam findings don’t affect post-test probability much. Labs and an ultrasound probe are better for liver pathology, and the exam alone cannot diagnose pancreatitis. 

Pearl – POCUS is key to identifying ascites. Look in RUQ, LUQ, paracolic gutters, and behind the bladder (men), and uterus (women). Sonographic Murphy’s has an +LR 9.9 for acute chole, BUT clinician gestalt +LR of 25-30!

Ep. #262 Iron Deficiency and Anemia of CKD 

produced by Stuart Brigham 

Pearl – KDIGO discusses absolute iron deficiency and relative iron deficiency. 

Absolute iron deficiency is:

1. Transferrin saturation (tsat) of under 20 percent and
   1. Ferritin under 30 (patients without CKD), 
   2. Ferritin under 100 in non-dialysis CKD, 
   3. Ferritin under 200 in CKD on dialysis. 

Relative iron deficiency occurs when ferritin is in the normal range, but tsat is under 20 percent. Note: When the tsat is above 30 percent, and ferritin is over 500, additional iron therapy is unlikely to benefit. 

Pearl – Oral iron maybe has a bum rap.  As we have discussed before, every other day dosing improves absorption, and we may have been overstating constipation (NNC = 10).  It’s reasonable to try oral iron first (e.g. for 1 to 3 months), and transition to IV iron if the patient is not responding or develops side effects.

Pearl – ESAs have caused real harm in previous trials via increased major adverse cardiac events (MACE). Use caution in patients with uncontrolled hypertension. The goal is no longer to normalize hemoglobin, and a value of 9 to 10 gm/dL is adequate for most patients. Dr. Topf and colleagues treat recommended treating anemia based on symptoms, NOT just numbers.

Check out the NephMadness 2021 Anemia region scouting report https://ajkdblog.org/2021/03/01/nephmadness-2021-anemia-region/ 

Ep. #266 Acute Diarrhea with Dr. Iris Wang 

produced by Elena Gibson with Graphic by Elena Gibson

Pearl – Testing to identify a source is a mixed bag. On the one hand, many patients are better before culture results, AND…the giant PCR panels may identify harmless colonizers. On the other hand, C. diff is now in the community and should always be considered (even without classic risk factors). Thus, testing for C. diff is reasonable if diarrhea beyond 72 hours.

Pearl – We talked about dysentery, which had a very Oregon Trail feel to it. Dysentery, or bloody stools, must be differentiated from rectal outlet bleeding.  When present, it warrants a microbiologic evaluation. Testing is also indicated for diarrhea that is severe (especially if lasting beyond 72 hours), or in immunocompromised patients. 

Pearl – Post-infectious diarrhea can occur when the initial infectious insult causes erosion of the villi. Lactase lives at the top of villi, so post-infectious lactose intolerance can develop. Additionally, some patients develop post-infectious IBS. 

Pearl – Consult a dietician if implementing the FODMAP diet and be sure to stress that it is meant to be a temporary diet to identify problem foods. 

Pearl – Focus on hydration during acute diarrhea. Use oral rehydration (WHO solution – packets available for purchase, or mix “half a small spoon of salt and six level small spoons of sugar dissolved in one litre of safe water”) when possible. Give IV hydration if too sick for PO fluids. 

Pearl – Antidiarrheals are generally safe in adults who don’t have ileus, and are at low risk for toxic megacolon (e.g. from C. diff, or IBD). 
Pearl – Bismuth subsalicylate is antisecretory (salicylate), antimicrobial (bismuth) —DynaMed. The combo may have some anti-inflammatory action as well (per UpToDate and DynaMed). It has labeled indications for diarrhea, dyspepsia, and travelers’ diarrhea!

Goal

Listeners will review tops pearls from recent curbsiders episodes

Learning objectives

After listening to this episode listeners will…

1. Diagnose and treat peripheral arterial disease
2. Recall key concepts and limitations of the abdominal exam
3. Evaluate iron status and select the appropriate treatment for iron deficiency in CKD
4. Develop a framework to evaluate and manage acute diarrhea

Disclosures

Drs. Watto and Williams report no relevant financial disclosures. 

Citation

Watto MF, Williams PN. “#271 TFTC #4: PAD, Abdominal Pain, Iron Deficiency in CKD, and Acute Diarrhea”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list Final publishing date April 28, 2021.