Diseases of the Gallbladder
1. Cholelithiasis (Stones in the gallbladder)
2. Acute Cholecystitis (Inflammation from stones obstruction and Injury > Infection)
3. Acalculous Cholecystitis (Idiopathic, often associated with severe diseases and Ischemia)
4. Choledocholithiasis (Stones obstructing bile duct)
5. Cholangitis (Inflammation of the duct due to Obstruction, Life threatening, Bacteria Overgrowth)
6. Carcinoma of gallbladder (Chronic Obstruction and Cholecystitis, Porcelain gallbladder)
7. Primary Sclerosing cholangitis (Hardening and Narrowing of the duct, Idiopathic)
8. Primary Biliary Cirrhosis (Autoimmune disease of the duct causing cirrhosis)
9. Cholangiocarcinoma (Carcer of the Bile duct)
10. Choledochal cysts (Usually Congenital cysts of the biliary tract)
11. Bile Duct Strictures (Abnormal narrowing due to different causes)
12. Biliary Dyskinesia (Sphincter of Oddi dysfunction)

Note
- In Diagnosis
US is often used for Gallbladder diseases
Cholangiography (also in mgt) is often used for Biliary duct disease/Obstruction
CT is used to confirm complications such as abscess and perforation
Biopsy is confirmatory in cirrhosis and cancer
- As a rule, Dx and Tx go from less invasive and easy to perform to more complicated as long as they are effective
- Every disease of the tract affects both Extrahepatic and Intrahepatic duct except Primary Biliary Cirrhosis (Autoimmune PBC)

Cholelithiasis
Cholelithiasis refers to Stones in gallbladder
3 types
1. Cholesterol stones
- Yellow/Green in colour
- Associated with Hypercholesterolemia.
2. Pigment stones
- Black or Brown stones
- Black is associated with Xcess bilirubin of any cause and alcoholic cirrhosis
- Brown takes the colour of bilirubin (brown) because bilirubin is already secreted, gets obstructed and solidifies to brown stones.
3. Mixed stones
- cholesterol and pigment stones (Black and/or Brown)
- Accounts for majority of stones (Some formed from obstruction (brown), some formed from xcess xterol)

Cholesterol stones
Associated with conditions with increased body cholesterol
1. Metabolic syndromes
2. Increased Exposure to Preg. hormones
3. Ileal dysfnx
- In resection,
- In chrons disease - Crohns affecting ileum = ileum inflammation, ileum can't reabsorb bile salts = xterol cummulate,
Remember that bile salts are synthesized from cholesterol
4. Advanced age (correlation is due to increased body fat in older peeps = inc. xterol)
5. Native American ancestry
6. Cirrhosis
- Cholesterol stones develop due to dysfnx and obstruction of gallbladder,
- Also cholesterol stones develop due to poor synthesis of bile salts from xterol due to loss of liver fnx.
- Liver synthesizes bile salts.
7. Cystic Fibrosis 
due to clogging of duct with thick mucous)

Pigment stones
- Black stones  (Black often due to xcess bilirubin from xcess hemolysis)
- Often found in
1. Hemolysis
2. Alcoholic cirrhosis
Brown stones Drown in the Ducts
Brown stones
- found in Bile ducts
- due to Biliary tract infection
-- Leads to inflammation
-- Inflammed duct causes obstruction of bile = Accumulation = Brown stones

Clinical Presentation of Cholelithiasis
1. Assymptomatic (Often incidental finding)
2. Biliary colic
- Defined as sudden pain in Epigastric region (esp. RUQ) due to gallstone blocking cystic duct
- Also called Gallstone attack
- A cardinal symptom of gallstone
- Pain occurs after feeding when the gallbladder contracts against this obstruction.
- Biliary colic is also common at night
- Pain usually lasts for atmost a few hours
- Pain varies in severity
3. Boas sign
- Pain of Biliary Colic referred to Right Subscapular region
- Remember Boas sign as a pain snake extending from the RUQ region to the subscapular region
 
Complications of Cholelithiasis
Think of
- Stones causing injury (hence inflammation)
- Stones passing out to block the duct
- Stones passing out to block the ileum (ileus) 
1. Cholecystitis (Acute or Chronic)
- Inflammation of the cyst
- Could be due to the stones causing inflammation due to chronic injuries to gallbladder wall during contraction.
- Also Stones causing obst may lead to stasis and overgrowth of bacteria = Inflammation
2. Choledocholithiasis
- means stones in the Bile duct
- occurs coz d gallbladder forces a stone out, but the stone gets stuck in the duct
3. Gallstone ileus
- Stone successfully passes through the duct but gets stuck in the ileum
- could also be as a result of fistula between the Gallblader and the intestine
4. Malignancy
- as a result of chronic inflammation and repair.

Diagnosing Cholelithiasis
1. RUQ ultrasound (preferred)
- High Sensitivity and Spec for stones > 2mm
- Cheaper and easily achievable
2. CT scans and MRI

Treatment for cholelithiasis
1. Elective cholecystectomy
- only for symptomatic pts

Acute Cholecystitis
- Acute inflammation of the gallbladder due to injuries from gallstones and obstr of the cystic duct.
- Recurrent acute cholecystitis can lead to Chronic cholecystitis

Symptoms of Acute cholecystitis
1. Pain
- Pain may last several days vs Biliary colic lasting few hours
- localized to RUQ and Epigastrium
- May also see Boas sign
2. N/V (Due to gastric irritation)
3. Anorexia/Loss of Appetite

Signs
Acute Cholecystitis is inflammation
Expect to see the signs of inflammation, such as Pain, Inc. WBC, fever etc
1. RUQ tenderness/rebound tenderness
2. Murphy sign (Not always present)
- described as inspiratory arrest on deep palpation of RUQ
- Pathognomonic
3. Hypoactive bowel sounds??
4. Fever (Low grade)
5. Leukocytosis

Diagnosis of Acute Cholecystitis (HIDA scan)
1. RUQ US
- Test of choice coz its cheap, Non-invasive and convenient.
- High Sens and Specs
- Thickened gallbladder wall
- Pericholecystic fluid (Fluid around the gallbladder)
- Distended gall bladder
- Stones in gall bladder
2. CT
Use if you suspect complicatns
- Perforation
- Abscess
- Pancreatitis (Seems CT is more sensitive for use in Pancrease vs US for Gall bladder)
3. HIDA scan
- As good as US
- Use if US is inconclusive
- Rules out Acute cholecystitis
- attempt to visualize Gallbladder 4 hrs after inject

Treatment of Acute Cholecystitis
1. Admit pt because pt is very sick
2. Conservative Mgt
- Prevent further injury with Fasting
- IV fluids (For hydration and compenstae for fasting)
- IV antibiotics for infection
- Analgesic for pain
- Correct electrolyte abnormalities
3. Surgery
- Preferred Early (24-48hrs) cholecystectomy for symptomatic.
- High recurrence if no surgery is done

Acalculous cholecystitis
- No stones obstructing the gallbladder or duct
- approx 10% of acute cholecyttitis
- Idiopathic
- Seen in
1. Severe underlying illness
2. Dehydration
3. Ischemia
4. Burns
5. Severe trauma
6. Postoperative state.
- Treatment 
1. Emergent Cholecystectomy (Choice)
2. Percutaneous drainage with Cholecystostomy for very ill pts

Choledocholithiasis
Refers to stones in the common bile duct (CBD)
1. Primary choledocholithiasis
- Stones develop in the CBD
2. Second choledocholithiasis (Most common)
- Stones dev. in the gall bladder but gets stuck in the common bile duct
Symptoms of Choledocholithiasis
General symptoms that indicate obstruction of the Gallbladder and duct
- RUQ Pain
- Jaundice
- Pruritus (due to accumulation of bile ducts in the blood secondary obstruction) 
 
Signs of Choledocholithiasis
Mostly signs of Biliary tract obstruction
Increased
1. ALP (not specific for gallbladder, may also indicate bone etiology)
2. Gamma-glutamyl transferase (GGT) (More specific for gallbladder disease)
3. Direct Bilirubin -
- Liver fnx properly, and indirect bilirubin is conjgated with glucoronide to become direct bilirubin.
- Direct bilirubin is then secreted in bile
- Due to obstructed, its accumulates in the serum
4. Jaundice
- Yellowing of skin and Mucous membranes
- Due to accumulation of bilirubin
Others
- Pruritus
- Clay colored stools (due to lack of bilirubin in bile brown pigment)
- Dark urine(From excess excretion of accumulated bilirubin in urine)

Diagnosing Choledocholithiasis
1. Initial study is RUQ US
2. Signs of Obstruction and Biliary Tract disease
3. Cholangiography is the Gold standard
- ERCP is Gold standard (High Sens and Specs)
- PTC is alt

Treatment for Choledocholithiasis
- As a rule, Dx and Tx go from less invasive and easy to perform to more complicated as long as they are effective
1. ERCP with Sphincterotomy
2. Stone extraction with Stent placement
3. Laparoscopic choledocholithotomy

Cholangitis
Life threatening Inflammatory reaction from infection of Biliary tract
- Due to Obstruction of bile duct, Injury from stones and Biliary stasis and Bacteria overgrowth
- Obstruction = Biliary stasis = Overgrowth of bacteria = Infection and Inflammation

Causes of Cholangitis
- conditons that obstruct the bile duct and cause stasis
1. Choledocholithiasis (Stones obstructing the CBD)
2. Pancreatic and Biliary tumors cauisng obstruction
3. Postoperative strictures (From scarring) which occlude the duct
4. ERCP and PTC - these may cause acute inflammation and eventual scarring and occlusion
5. Choledochal cysts (Cysts in the bile duct) causing obstruction and stasis.

Symptoms of Cholangitis
Genral symptoms of Gallbladder disease plus Systemic inflammatory reaction (Life threatening)
1. RUQ pain
2. Fever (due to immune activation)
3. Dizziness (Same mechanism as AMS)
4. Altered Mental capacity (Due to decreased cerebral perfusion from systemic vasodilation)
5. May show signs of AKI in severe cases

Signs
1. Charcot Triad
Signs of Gallbladder infection and Obstruction
- RUQ pain
- Jaundice
- Fever
2. Reynolds pentad
- Signs of Gallbladder disease and other systems affected (CNS and CardioVascular)
- RUQ pain
- Jaundice
- Fever
- Septic shock
- Altered Mental Stasus
Reynolds is Reypidly fatal

Diagnosing Cholangitis
1. RUQ US
2. Blood tests
- Hyperbiirubinemia
- WBCs
- Mild inc in Transaminases
3. Cholangiography
- Definitive tests
- Identifies cause
- Contraindicted in the acute phase of cholangitis (done after 48hrs of afebrile)
- PTC when duct is dilated
- ERCP when duct is normal

Treatment of Cholangitis
1. Admission
2. IV fluids
3. Blood cultures requested
4. IV antibiotics
5. Close monitoring of systems
- Decompress CBD through Cholangiography
Done after pt is afebrile for 48hrs or when pt wont respond to tx
1. PTC (Catheter drainage)
2. ERCP (Sphincterotomy)
3. Laparotomy (T-tube insertion)

Gallbladder Carcinoma
- Adenocarcinomas
- Elderly
- Undetected until End stage
- Risk factors = Stones, Fistula and Porcelain
- Symptoms and Signs suggest Obstruction, gallbladder disease and malignancy
- Palpable gallbladder = Advanced disease
- Treatment
Surgical = Cholecystectomy/Radical
- Poor prognosis

Primary Sclerosing Cholangitis (Hardens the Ducts till they form beads)
- UC associated with PSC
- Idiopathic
- Chronic and progressive
- Idiopathic Inflammation = Scarring = Occlussion of ducts
- Affects any of the ff
1. Intrahepatic bile ducts
2. Extrahepatic bile ducts
3. Both
- Associated with Ulcerative Colitis (UC)

Signs and symptoms
- Insidious
- Signs and symptoms are those of duct obstruction due to Sclerosing of the bile duct
- Malaise, fatigue and weight loss are present in all also due to malabsorption.

Diagnosing of Primary Sclerosing Cholangitis
Cholangiography
- see multiple areas of bead-like stricturing and bead-like dilations of affected ducts.

Treatment for Primary Sclerosing Cholangitis 
Treatment is usually symptomatic
- Cholestyramine for itching
- Cholangiography to relieve obstruction
- Definitive  cure is liver transplant

Primary Biliary Cirrhosis (PBC)
- Autoimmune PBC
- A disease condition xterized by destrcution of Intrahepatic bile ducts. (Unlike PSC that involves Intrahepatic and Extrahepatic)
- Leads to cholestasis
- An autoimmune disease
- common in middle aged women

Signs and Symptoms of Primary Biliary Cirrhosis
- Are related to both Gallbladder obsr and Liver cirrhosis
1. Pruritus and Jaundice (From accumulaion of Bile salts and Bilirubin)
2. RUQ discomfort
3. Hypercholesterolemia
- inability due produce bile from xterol due to accumulation and progressive loss of liver fnx
4. Osteoporosis signs and symptoms
- Occurs because Liver cannot properly prd 25-HO vit D
5. Signs and Symptoms of Portal HTN
- due to destruction of perivascular live tissue

Diagnosing of PBC
1. Cholestatic LFTs
- ALP
- Gamma-glutamyl transferase (GGT)
2. +ve AMA
- Sensitive and Specific
- Rules out disease if -ve
- Hallmark
- Confirm with Liver biopsy
3. Elevated IgM
- because its an autoimmune disease
4. US or CT
- check for obstruction that may be relieved.

Treatment of PBC
1. Symptomatic
2. UDC acid for PBC
- Ursodeoxycholic acid
- Slows progression of disease
3. Definitive cure is Liver transplantation

Cholangiocarcinoma
A tumor of Intrahepatic or Extrahepatic bile duct
Common in old > 70
Affects 3 regions
1. Proximal third of Common Bile Duct (CBD)
-  Klatskin tumor
2. Distal Extrahepatic
- Better resectability
3. Intrahepatic (Least Common)
Prognosis is poor

Risk factors
are diseases affecting the Intrahepatic/Extrahepatic ducts
- Primary Sclerosing Cholangitis (PSC)
- Choledocholithiasis (Stones in CBD)
- Choledocyts (Congenital cysts)
- Clonorchis Sinesis (Hong Kong)

Signs and Symptoms of Cholangiocarcinoma
- Are those of 
1. Obstruction - eg Pruritus, Jaundice
2. Malignancy - palpable mass
3. Malabsorption - Weight loss, Oily stools

Diagnosis of Cholangiocarcinoma
Same diagnosis for all Biliary tract disease
1. Cholangiography
- Detects unresectable tumours
 
Treatment of Cholangiocarcinoma
- Most common tumors (Klatskin)  are not resectable
- Mostly paliative
1. Cholangiography with stent placement to relieve obstruction

Choledochocysts
- Cystic dilation of the Biliary tree
- usually congenital
- common in women
- Causes pncreatitis
- involves the
1. Extrahepatic bile duct
2. Intrahepatic bile duct
3. Both

Complications
are those of prolonged obstruction, liver disease and malignancy
1. CholangioCA (Most feared, 20%)
2. Hepatic abscess
3. Pancreatitis
4. Cirrhosis

Diagnosing Choledochocysts
1. Ultra Sound (US) to detect obstruction
2. but remember Cholangiography is definitive for the ducts
3. CT is good for detecting complicatins like peforation, Abscess etc

Treatment for Choledochocysts 
- Complete resection of cyst
- Enterobiliary anastomoses to restore continuity of biliary system.

Bile Duct Stricture
Refers to narrowing of the the bile duct

Common cause is Iatrogenic (eg A surgery around the gallbladder/billiary tract)
Other causes include diseases causing obstruction and narrowing of the bile duct.
e.g Primary Sclerosing Cholangitis

Signs and Symptoms
Include those of Obstructed bile ducts and their complications

Common complications
1. Secondary Biliary Cirrhosis
2. Liver abscess
3. Ascending cholangits

Treatment for Biliary Stricture
1. Endoscopic Retrograde CholangioPancreatography (ERCP) stenting
2. Surgical bypass if complete obstruction/ErCP fails

Biliary Dyskinesia
- Motor dysfunction of the Sphincter of Oddi
(Spincter of Oddi is the outlet of the CBD and Pancreatic duct
- Leads to episodes of Biliary Colic
- No evidence of gallstones on diagnostic studies

Symptoms
Biliary colic

Diagnosing Biliary Dyskinesia
1. Hepatobiliary IminoDi Acetic acid (HIDA) scan + Cholecystokinin (CCK)
(CCK contracts gallbladder as it relaxes the Sphincter of Oddi)

Treatment for Biliary Dyskinesia
- Open the sphincter or stop the pain and prevent complications 
1. Laparoscopic Cholecystectomy (Prevents colic/Complications)
2. ERCP sphincterectomy (creates a passage)

Congestive Heart Failure
- Hearts inability to meet body's normal circulatory demand
- There are various causes of Congestive Heart Disease
- Heart failure might be asymptomatic on mild exertion
- Could be due to Systolic or Diastolic dysfunction

Systolic dysfunction (Pump dysfunction)
- Decreased ejection fraction
- Due to 
i. Obstruction of flow (eg in aortic stenosis)
ii. Contractility dysfnx (eg in LV hypertrophy)

Causes of Systolic Dysfunction

Common causes
1. Hypertension
2. Myocardial Infarction
3.Valvular diseases
4. Myocarditis

Less common causes (HART)
1. Hemochromatosis
- Excessive deposition of iron in cardiac muscles inorder of Epicardium, Myocardium and Endocardium
- Catalyzed by the rapid Fenton reaction to hydroxyl ions (ROS) 
- ROS cause Leak of hydrolytic enzymes which initiate cell damage 
- Hemochromatosis can accelerate ischemia-induced reperfusion injury 
- Process is reversable

2. Alcohol overuse
- LV myocyte loss, -ve inotropy and depressed contractility  
- myocyte dysfunction (abnormal calcium homeostasis) 
- Increased LV dilation/Mass and/or reduced wall thickness (Dilated cardiomyopathy) 

3. Radiation
- Acute and chronic effects on the heart.
- Acute effects by TNF, IL-1, 6, and 8 plus neutrophil infiltration. (asymptomatic/pericarditis)
- Chronic effect induces fibrosis (IL-4, IL-13, and TGF-β)
- A decrease in elasticity and distensibility
- Endothelial damage (fibrotic changes), lipid and inflammatory cell infiltration, and lysosomal activation
- Certain risk factors like smoking and hyperlipidemia may act as accelerating agents. 

4. Thyroid abnormalities (thyrotoxic cardiomyopathy)
- Altered myocyte energy production, intracellular metabolism, and myofibril contractile function.
- Left ventricular hypertrophy
- Heart rhythm disturbances
- Primary atrial fibrillation
- Dilation of the heart chambers

Diastolic dysfunction (Filling dysfunction)
- Impaired ventricular filling
- may be due to impaired relaxation (e.g In hypertrophy)
- may be due to Increased stiffness (e.g in Sarcoidosis)
- Less common compared to systolic dysfunction

Causes of Diastolic dysfunction
- Myocardial Hypertrophy (Failure of LV to relax properly in Atrial systole)
- Valvular diseases (eg In Mitral Stenosis)
- Restrictive cardiomyopathy
i. Amyloidosis
ii. Sarcoidosis
iii. Hemochromatosis

High Output Cardiac failure
- An increase in CO is needed for the requirements of peripheral tissues for oxygen
- Abnormaly increased requirement of Oxygen by peripheral tissues

Causes of High Output Cardiac Failure (Mitral TAP TAAP)
1. Miral Regurgitation
2. Thymine deficiency (Wet Ber1 Ber1)
3. Anemia (Chronic)
4. Pregnancy
5. Thyroid abnormal high (Hyperthyroidism)
6. AV shunts
7. Aortic insufficiency
8. Paget disease of bone

Symptoms of Left Heart Failure
- Mostly due to High pressure transmitted to the Lungs and reduced Cardiac output

1) Dyspnea
- Due to Pulmonary Edema – Blood spilling into the Alveoli

2) Orthopnea
– Difficulty breathing in recumbent position due to increased preload
- Since veins are not flowing against gravity

3) Paroxysmal Nocturnal Dyspnea
- Awakening after 1-2 hrs of sleep due to acute shortness of breath

4) Nocturnal cough

5) Confusion and Memory Impair
- Due to reduced blood supply to Brain
- Common in advanced disease

6) Diaphoresis and Cold extremities
- The sympathetic system is activated due to reduced blood flow reaching organs (especially kidneys)
- Due to Constriction of peripheral vessels to shunt blood to the internal organs - - - -- Diaphoresis (Stimulated by Sympathetics) Sympathetics also cause sweating

- Occurs in worsening CHF

Signs of Left sided CHF
- The Signs confirm/explain the symptoms of the patients

1) Displaced Apex beat (Point of Maximum Impulse)
- In Adults normal apex beat is palpated in the precordium left 5th intercostal space, half inch medial to the left midclavicular line and 3-4 inches left of left border of sternum.
- In children the normal apex beat occurs in the fourth rib interspace medial to the nipple.
- It is displaced when it is palpated lateral to the normal, or when it is felt on a larger surface of the palm

2) Pathologic S3 (Rapid filling into non-compliant left ventricle e.g in hypertrophy)
- Increased filling pressure
- S3 = Heard at Ap3x with b3ll of stethoscope
- Sp3cific for CHF
- Normal in kids
- It is called a ventricular gallop
- S3 is Sp3cific

3)S4 gallop (atrial systole into Sti4ned ventricles)
- Due to ejection into Stiff (Sti44) ventricles
- Hear in either of 2 places depending on affected ventricle (Left or Right)
- If Stiff Left Ventricle = Apex with patient in left lateral decubitus position (Or on expiration/exercise)
- If stiff Right Ventricle = Left sternal border (louder with exercise and deep quick inspiration)

4) Crackles
- Due to Pulmonary edema
- They cause dyspnea
- Crackles are caused by the "popping open" of small airways and alveoli collapsed by fluid.
- They are often bibasal 

5)Dullness on Percussion/Decreased Fremitus
- Often in the lower lung fields
- Are usually due to pleural effusion
- Pleural effusions in CHF are due to elevated pulmonary capillary pressure.
- Pleural effusion in heart failure results from increased interstitial fluid in the lung 
- These Pleural effusion are usually bilateral > Unilateral and can be worse on the left > right
- These pleural effusions can be Transudates > Exudates

6)Increased intensity of Pulmonic component of second heart sound
- Due to pulmonary Hypertension

Symptoms/Signs of Right Heart Failure
- Due to increased pressure in the right heart transmitted to the veins
1. Pitting Peripheral Edema
- Usually unspecific finding
- can be due to other causes 

2. Jugular Venous Distention

3. Hepatomegaly

4. Hepatojugular reflux

5. Right Ventricular heave/Parasternal heave
- A parasternal heave (lift) is a precordial impulse that may be felt (palpated) in patients with cardiac or respiratory disease
- Parasternal heave can occur in the setting of right ventricular enlargement
- The right ventricle is most anterior (closest to the chest wall).
- In a normal right ventricle no impulse or a slight inward impulse is felt

6. Nocturia
- Often early in the course of heart failure.
- Recumbency reduces the deficit in cardiac output in relation to oxygen demand
- Pooling of blood in the lower extremities is reduced and heart isnt pumping against gravity
- Renal vasoconstriction diminishes, and urine formation increases.
- Prevents them from obtaining much-needed rest.

7. Ascitis
- Due to increased pressure gradient in the portal vein
- Nausea
- Bloating
- Abdominal pain
- Loss of appetite

Tests to order in Congestive Heart Failure
- To find the causes of Heart Failure
- To explain the symptoms of Heart Failure
- To detect worsening Heart Failure

Chest X-ray
- Detects
i. Pulmonary Edema (Pulmonary Edema cause dyspnea)
ii. Cardiomegaly (Cardiomegaly may be the cause of CHF)
iii. Rules out COPD (A differential for dyspnea)

ECG
- Detects cause of CHF

Cardiac Enzymes
- Rules out MI as cause

CBC
- Rules out Anemia (Chronic Anemia is a cause of High output Cardiac failure)

Echocardiogram
- Estimate EF (Diastolic/systolic dysfnx)
- rule out pericardial effusion

Radionuclide Ventriculography using technetium

Catheterization
- Rules out CAD as cause of CHF

Stress Testing

Chest X-Ray in CHF 

1. Cardiomegaly

2. Kerley B lines
- These are short parallel lines (thin linear pulmonary opacities) at the lung periphery.
- Often due to interstitial pulmonary edema (fluid or cellular infiltration into the interstitium of the lungs) 
- Often at the lung bases near the costophrenic angles on the PA radioaph
- Mostly at the substernal region on lateral radiographs

3. Increased Interstitial markings
- As a result of the increased pressure in the capillaries = increased fluids in interstitium
- leakage of fluid into the interstitium (interlobular and peribronchial) and the pleural space and finally into the alveoli resulting in pulmonary edema.
- Fluid in the peripheral interlobular septa is seen as Kerley B or septal lines.

4. Pleural effusion
- Leakage of fluids into the pleural space
- Pleural effusion is bilateral in 70% of cases of CHF.
- When unilateral, it is slightly more often on the right side than on the left side.

Echocardiogram
- Transthoracic
1. Initial Test of choice
2. Determines if Systolic or Diastolic dysfunction predominates
3. Determines cause
4. Estimates EF(< or > 40%)
5. Shows Chambers (Dilatation/Hypertrophy)

ECG
- Usually Non-Specific
- helps determine cause of CHF
i. Chamber enlargement
ii. Ischemic Heart Disease

Radionuclide ventriculography using technetium-99m
- Called MUltiGated Acquisition (MUGA) scan
- Uses Technetium-99m(99mTc) as radioactive material
- A gamma camera is used to create an image following injection of 99mTc labeled red blood cells.
- The Radionuclide has the property of circulating through the cardiac chambers. 
- In perfusion imaging, radionuclide is taken up by the myocardial cells, making its presence correlate with myocardial perfusion or viability of the cells.
- Evaluates CAD, cardiomyopathy, Valvular and Congenital Heart diseases.
- Radioactive material is retained in the patient for several days (may trigger security alarms)
- Gives a much more precise measurement of left ventricular ejection fraction 
- Used in monitoring cardiac function in chemotherapy

Cardiac catheterization
- Gives quantitative info of diastolic and systolic dysfunction
- Clarify cause of CHF
- Consider coronary angiography to exclude CAD as cause

Stress testing
- Detects ischemia
- Detects level of Myocardial conditioning 
- Differentiates etiology of dyspnea (COPD and Cardiac origin)
- Dynamic response of HR, rhythm and BP

B-type Natriuretic Peptide (BNP)
- Released from ventricles
- Released in response to ventricular volume expansion and pressure overload
- > 150pg/mL correlates with decompensated CHF
- useful in differentiating dyspnea (CHF and COPD)
NT-proBNP
- newer assay
- normal range depends on age of patient
- 40 days post MI
ii. EF < 35%
iii. Symptomatic Class 3 or 4 despite adequate therapy

Cardiac Resynchronization Therapy (CRT)
- Biventricular pacemaker
- Indicated for patients who have indications for ICD + Prolonged QRS duration (> 120msec)
- Most patients receive a combined device (ICD and CRT)

Cardiac transplantation
- Last alternative after all treatment modality have failed

Diastolic dysfunction treatmet
- Treatment is symptomatic
- B-blocker
- Diuretics 
- ACEI (Unclear benefits)
- ARBs (Unclear benefits)

Contraindicated in Diastolic dysfunction
- Digoxin
- Spironolactone

General Contraindications in CHF
1. Thiazolidinediones
2. Anti-Arrhythmics
3. Metformin
4. NSAIDS

Thiazolidinediones (Rosiglitazone, Pioglitazone)
- Also known as glitazones
- A group of oral Hypoglycemic drugs for DM2
- Works on the Fats and Muscles to reduce Insulin resistance
- May cause Hepatotoxicity 
- Act on renal peroxisome proliferator-activated receptor gamma (PPAR-y) to increased sodium retention. 

Anti-Arrhythmics (Only B-blockers shows clear benefit with less side effects)
- Amiodarone is a great choice for arrhythmias in CHF, but it is highly toxic to other systems (esp. lungs)
- Most others are -ve inotropes and are proarrhythmics (Ironically) 

Pain killers (NSAIDS)
- COX-1 and COX-2 inhibitors
- Inhibits prostalgladins (vasodilators)
- Impair renal function in patients with a decreased effective circulating volume
- Leads to H20 and Na+ retention 

Calcium Channel Blockers
- They have no role in CHF
- They may increase mortality (increase hrt rate)
- Amlodippine and Felodipine are safe in CHF (Use only when indicated)

Acute Decompensated Heart Failure
- Refers to ACute Dyspnea + elevated left sided filling pressure
- mostly due to Sys or dia dysfnx
- Flash pulmonary edema

Diagnosis
- ECG
- CXR
- ABG
- B-type Natriuretic peptide (BNP)
- Echo
- Coronary angiogram iif indicated

Management
- Hospital Admission
- Oxygenation and Ventilatory assist (Non rebreather, NPPV, intubation)
- Diuretics (really important for symptoms)
- Na+ restriction
- Nitrates (For thsoe without hypotension)
- Acute inotrope (Dobutamine) for refracory P edema despite tx (digoxin takes weeks to work)

Limited evidence for use
- Moprhine sulfate

Determine effectiveness and response to treatment (Diuresis) by taking daily weigth of pt

Differentials of Acute Decompensated CHF

Other diseases causing rapid respiratory distress
- P. Embolism
- Asthma
- Pneumonia