海外実習：Day 1（Outpatient)

My Schedule 

• Fellowship Clinic (Morning)

  • GI fellow have their own clinic once a week. After the fellow meet with the patient, they consult to the attendee and look at the patient again with the attendee. 

  • In the afternoon, they went to the inpatient training at whatever hospital they were assigned to. There are some months in which the fellow only does outpatient clinic.

  • If you cross the border to Mexico, you are not legally allowed to the telemedicine. 

  • Translator is always available to connect to through the some sort of app. 

• Transplant Clinic (Afternoon) 

  • Check on pre and post transplant patients (mainly abdominal).

  • The doctor ("transplant  quarterback" ) talked with the patient. There were also registered nurse. After talking with the doctor, the patient meet the "team" consisting of social workers, nutritionist, and etc. 

  • Alcohol related -> usually at least 6 months of training is needed. However, there are some who need that transplantation quickly. If they did not know that they were alcoholic, it can be done in fewer months. 

Today's Learning

• Abnormal Liver Function Test

  • ①hepatocellular transaminitis (AST, ALT increase) ②cholestatic injury　③mixed

  • statin can cause abnormal liver function -> not clinically significant 

• Fibrosis

  • FIB-4 = {Age (years) x AST Level (U/L) } / {Platelet Count (109/L) x √ALT(U/L) }

    • FIB-4 score <1.45 had a negative predictive value of 90%

  • Ultrasound might not always catch fatty liver (echogenic) -> MRI (recently also contrast US) 

  • varices -> carvedilol (non-selective beta blockade, along with the alpha-1 blockade)

• HB serology

  • HBs antibody -> vaccinated or past exposure

  • HBc antibody -> previous exposure -> reactivation risk 

    • HB prophylaxis OR continuous monitoring with the PCR

    • depends on the different level of immunosuppression 

• Autoimmune Disease

  • Primary biliary cirrhosis (PBC)-> antimitochondrial antibody, IgM

  • Primary sclerosing cholangitis (PSC) -> pANCA (80% IBD)

  • Autoimmune Hepatitis -> antinuclear antibody (ANA) and anti-smooth muscle antibody (SMA),  IgG

• MELD score -> liver transplantation 

  • Each place has a different way of getting the liver? The average MELD score for each institution is different? You can be listed as donor in 2 different places? 

  • Right after the transplantation -> need to come to the clinic maybe 2 times in a week. They it starts to become longer, maybe once every 6 month or annually. The family needs to relocate. 

My Homework

• MELD score, Child pugh score 

• How to approach to the patient with abnormal liver tests

• Go over PBC vs PSC vs autoimmune hepatitis 

• Alcohol related liver problem -> transplantation 

反省会

• 挨拶をするタイミングが良く分からなかった。

• 午前のクリニックはみんな冗談を言いながら、楽しく仕事をしていた。会話の輪に入って良いのかどうか、分からなかったし、入りかたが分からなかった。->もっとfriendlyになれるように頑張りたい。Fellowの人達ともお話できるようになりたい。

• 午後は1対1だった。初対面だったけど、いっぱい教えてくれて、勉強になった。たぶん、変な質問もしたと思うけど、新しい学びが多かった。初めて、黄疸を見た！本当に目や皮膚って黄色くなるんだ！

• Alcohol related cirrhosisの方をみた。ひとりだと気づいたら飲んでしまう。治す意思があって、毎日、空きがないか電話している。そういった中でも、やはり飲むことは辞められない。依存って病気である事を改めて実感できた。