A competency based development of knowledge and skills in Hepatology through clinical experience, bedside teaching, didactic conferences and readings to achieve competence, proficiency and the foundation for mastery. Clinical Information and Didactics - The role of the residents will be to admit and manage inpatients on the pre-transplant hepatology service.
- Residents will admit from 7am to 7pm, daily with a cap of 12. At 7pm, admissions will be handled by nightfloat.
- Hepatology admission pager is 5-3667.
Interns are responsible for: - Picking-up sign-out from Intern Nightfloat B
- Complete all notes on the computer, except the plan which is added preferably during or shortly after rounds so that the notes can be promptly forwarded to the Attending for their addendum.
- Collect labs and vitals on patients
Resident expectations include: - Picking up any patients admitted to cardiology from the overnight Nightfloat residents between 6:45 and 7:00 AM
- 7:30am Morning Report
- Update service patient list with copies for the attending
- Attend the weekly Transplant meeting
- Lead rounds, diagnostic and management decisions on patients , prioritizing more urgent patients
Rounds - Rounds take place at 8:30 am in the conference room on the 11th Floor East unit which is the main geographic location of the pre-transplant hepatology patients.
- Formal teaching sessions covering topics discussed in "learning objectives" should occur during morning rounds 2-3 times each week. The fellow or attending should lead these teaching sessions
Admission Policies - Decision to admit patients to the hepatology service is at the discretion of the fellow covering the hepatology service – all potential admission should be discussed with the fellow prior to accepting the patient
- Chief medical residents are always available to assist in issues regarding patient disposition or management.
Conference Schedule
| Monday | Tuesday | Wednesday | Thursday | Friday | AM | 7:30 am Morning Report | 7:30 am Grand Rounds | 7:30 am GI Fellow’s Conference (Galter 4-133) | 7:30 am GI Educational Conference (Galter 8-234) | 7:30 am Hepatology-Transplant Conference (Galter 17th Floor) | PM |
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| 1:00 pm Resdient’s Conference (Galter 4-133) | 5:00 pm Med-Surg GI Conference (Galter 4-206) |
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Call Schedule - On weekdays: The Hepatology resident will admit patients between the hours of 7am-7pm. Interns will admit with the resident on a q3 cycle.
- The inpatient Hepatology resident and the Hepatology consult resident will alternate days for admitting until 7pm.
- Between 7pm-7am, Night float A1 resident will admit new patients to the service.
- On weekends:
- The Hepatology residents will have every Saturday off.
- On Saturdays, the Hepatology fellow will admit with interns between the hours of 8am-5pm. Between 5pm-8pm, a Northwestern General Medicine resident A will admit new patients.
- Hepatology fellow will have every Sunday off. There will be a covering GI/ Hepatology fellow to round with the team on that day.
- On Sundays, the inpatient Hepatology resident will admit with the interns. between the hours of 8am-5pm. Between 5pm-8pm, a Northwestern General Medicine A resident will cover.
- Night float A resident will continue to cover admissions between the hours of 7pm-7am.
Contact Numbers: - Dr. Steven Flamm, pager 695-2051
- Dr. Richard Green, pager 695-6897
- Judy McGowan (Division Secretary), Office 908-7280
Click here Practice Based Learning and Improvement PGY1: Incorporate regular chart review and patient follow up to learn from your clinical care. Teach and mentor students. PGY2/3: Incorporate evidence based medicine into clinical decision making. Review the latest research pertaining to your your patients. Teach and mentor students and interns. Systems Based Practice PGY1: Work in a multi-disciplinary team to provide high quality coordinated care. Ensure accurate and timely documenation through the use of the electronic medical record. PGY2/3: Use knowledge and skills in quality improvement and patient safety to deliver safe and effective care. Apply team leadership skills in appropriate settings. Practice cost effective medicine with an awareness of health care economics and patient insurance status. Interpersonal Skills and Communication PGY1: Use effective listening skills with patients and health care providers. Elicit and provide information using effective nonverbal, explanatory, questioning, and writing skills. PGY2/3: Develop interpersonal and communication skills necessary to run an effective clincal team in the ambulatory. Role model and teach effective communication techniques. Professionalism PGY1: Carry out your professional responsibilities in a timely manner. Adhere to the ethical principles of a patient-centered practice. Be sensitive to a diverse patient population and health care staff. PGY2/3: Understand how biases influence clinical care, patient-physician interactions and health team interactions. Role model and provide feedback to students and interns the principles of humanism in medicine. Patient Care and Medical Knowledge PGY-1 Manage and treat the complications of end stage liver disease. - Identify complications of cirrhosis.
- GI bleeding
- Ascites
- Encephalopathy
- Hepatorenal Syndrome
- Hepatopulmonary Syndrome
- Review the pathophysiology of portal hypertension and how it determines treatment options.
- Diagnose and treat complications of cirrhosis.
- GI bleeding
- Assess the risk of bleeding by being able to interpret endoscopic stigmata as well as portal pressure measurements.
- Recognize the indications for endoscopy, medical therapy, TIPS and surgical shunting.
- Ascites
- Determine the presence of ascites on examination.
- Interpret ascitic fluid studies (calculate and understand the concept of the albumin gradient)
- Identify spontaneous bacterial peritonitis and differentiate it from secondary bacterial peritonitis and contamination.
- Manage fluid overload in the cirrhotic patient using diuretics.
- Evaluate renal dysfunction in patients with cirrhosis (Discriminate hepatorenal syndrome from ATN/ Prerenal azotemia)
- Perform large volume paracentesis
- Discuss the indications for TIPS in the treatment of ascites.
- Encephalopathy
- Identify the precipitating factors in encephalopathy.
- Manage acute mental status changes in patients with cirrhosis.
Work up patients with acute liver failure. - Identify the causes of Acute Liver Failure.
- Recognize the common etiologies of liver failure and their potential treatments (ex. Tylenol overdose/ N-acetyl-cysteine)
- Predict the need for liver transplantation.
- Learn the triage algorithm for patients presenting with Acute Liver Failure.
- Describe the concepts of the King’s College Hospital Criteria for assessing liver transplant risk.
Evaluate and manage patients with chronic liver disease. - Identify the causes of chronic liver disease
- Viral Hepatitis
- Interpret serum hepatitis serologies in chronic hepatitis B infection.
- Review the natural history of chronic viral hepatitis.
- ETOH
- Non-alcoholic fatty liver disease (NASH)
- Inborn errors of metabolism (ex. Wilson’s, Hemachromatosis)
- List the various tests needed to diagnose these disease processes
- Cholestatic disorders
- Compare and contrast PBC and PSC
- Autoimmune disorders
- Select the most appropriate management option for the various causes of chronic liver dysfunction.
- Viral hepatitis
- IFN therapy versus other antivirals
- Inborn errors of metabolism
- Hemachromatosis
- Phlebotomy vs. chelating agents
- Cholestatic disorders
- Examine the medical literature and review the use of Ursodiol in PBC and PSC
- Autoimmune hepatitis
- Determine when Imuran therapy is needed to prevent complications of chronic prednisone therapy
Interpret abnormal Liver function tests - Identify the most common causes of abnormal LFT’s.
- Differentiate hepatic injury versus a cholestatic process.
- Select the appropriate initial lab tests to work up abnormal LFT’s.
- Recognize when referral for liver biopsy is needed.
PGY-2/PGY-3 Describe the indications for liver biopsy. - Recognize basic liver pathology and be able to recognize cirrhosis, fatty infiltration, alcoholic hepatitis and viral hepatitis on liver biopsy.
- List the possible complications of liver biopsy and how they can be prevented (i.e. transvenous versus percutaneous).
Liver Transplantation - Describe the classification scheme for allocation of donor organs.
- Review and debate the ethical issues regarding selection of liver transplant candidates.
- Alcohol abuse
- Suicide attempts
- Recognize the complications of liver transplant and chronic immunosuppression.
- Rejection versus immunosuppression
General Hepatology - Green RM, Flamm S. AGA technical review on the evaluation of liver chemistry tests. Gastroenterology. 2002; 123:1367-84.
- Naylor CD. Physical examination of the liver. JAMA 1994; 271:1859-65.
Cirrhosis and complications - Abraldes JG, Angermayr B, Bosch J. The management of portal hypertension. Clin Liver Dis. 2005; 9:685-713
- Arroyo V, Terra C, Gines P . New treatments of hepatorenal syndrome. Semin Liver Dis. 2006; 26:254-64.
- Blei AT, Cordoba J. Practice Parameters Committee of the American College of Gastroenterology. Hepatic Encephalopathy. Am J Gastroenterol. 2001; 96:1968-76.
- Gines P, Cardenas A, Arroyo V, Rodes J. Management of cirrhosis and ascites. N Engl J Med. 2004; 350:1646-54.
- Iwakiri Y, Groszmann R. The hyperdynamic circulation of chronic liver diseases: from the patient to the molecule. Hepatology. 2006 Feb;43(2 Suppl 1):S121-31
- Krowka MJ. Evolving dilemmas and management of portopulmonary hypertension. Semin Liver Dis. 2006; 26:265-72.
- Palma DT, Fallon MB. The hepatopulmonary syndrome. J Hepatol. 2006; 45:617-25.
- Plauth M et al. ESPEN Guidelines on Enteral Nutrition: Liver disease. Clin Nutr. 2006; 25:285-94. Epub 2006 May 16.
- Rimola A et al. Diagnosis, treatment and prophylaxis of spontaneous bacterial peritonitis: a consensus document. International Ascites Club. J Hepatol. 2000; 32:142-53.
- Wiest R, Garcia-Tsao G. Bacterial translocation (BT) in cirrhosis. Hepatology. 2005; 41:422-33.
- Wong F, et al. Sepsis in cirrhosis: report on the 7th meeting of the International Ascites Club. Gut. 2005; 54:718-25.
Steatohepatitis - Levitsky J, Maillard ME. Diagnosis and therapy of alcoholic liver disease. Semin Liver Dis 2004; 24:233-247.
- Maher JJ. Alcoholic clasteatosis and steatohepatitis. Gastrointest Dis. 2002; 13:31-9.
- O’Shea RS, McCullough AJ. Treatment of alcoholic hepatitis. Clin Liver Dis. 2005; 9:103-34.
- Farrell GC, Larter CZ. Nonalcoholic fatty liver disease: from steatosis to cirrhosis. Hepatology. 2006; 43:S99-S112.
Viral Hepatitis - Feld JJ, Liang J. Hepatitis C -- identifying patients with progressive liver injury. Hepatology. 2006; 43:S194-206
- Flamm S. Chronic hepatitis C virus infection. JAMA 2003; 289:2413-7.
- Martin A, Lemon S. Hepatitis A virus: from discovery to vaccines.Hepatology. 2006; 43:S164-72
- Pawlotsky JM. Therapy of hepatitis C: from empiricism to eradication. Hepatology.2006; 43:S207-20.
- Perrillo RS. Therapy of hepatitis B -- viral suppression or eradication? Hepatology. 2006; 43:S182-93.
- Yim HJ, Lok AS. Natural history of chronic hepatitis B virus infection: what we knew in 1981 and what we know in 2006. Hepatology. 2006; 43:S173-81.
Acute Liver Failure - Larson AM et al. Acetaminophen-induced acute liver failure: results of a United States multicenter, prospective study. Hepatology. 2005; 42:1364-72.
- Polson J, Lee WM. American Association for the Study of Liver Diseases. AASLD position paper: the management of acute liver failure. Hepatology. 2005; 41:1179-97.
- Vaquero J, Blei AT. Etiology and management of fulminant hepatic failure. Curr Gastroenterol Rep. 2003; 5:39-47
Hepatocellular carcinoma - Bruix J et al. Chemoembolization for hepatocellular carcinoma. Gastroenterology. 2004; 127:S179-88.
- Di Bisceglie AM. Issues in screening and surveillance for hepatocellular carcinoma. Gastroenterology. 2004; 127:S104-7.
- Fattovich G et al. Hepatocellular carcinoma in cirrhosis: incidence and risk factors. Gastroenterology. 2004; 127:S35-50.
- Kulik LM, Abecassis M. Living donor liver transplantation and hepatocellular carcinoma. Gastroenterology 2004; 127: S277-284.
- Llovet JM, Schwatrz M, Mazzaferro V. Resection and liver transplantation for hepatocellular carcinoma. Semin Liver Dis. 2005; 25:181-200.
Liver Transplantation - Charlton M. Recurrence if hepatitis C after liver transplantation. Liver Transplantation 2005; S57-S62
- Merion RM. When is a patient too well and is a patient or too sick for a liver transplant? Liver Transplantaiton 2004; 10: S68-S72.
- Munoz S, Elgenaidi H. Cardiovascular risk factors after liver transplantation. Liver Transplantation 2005; S52-6.
- Olthoff K et al. Summary Report of a Natinal Conference: Liver allocation in the MELD and PELD era. Liver Transplantation 2004; 10: A6-A22.
- Shiffman ML, Saab S, Feng S, Abecassis MI, Tzakis AG, Goodrich NP, Schaubel DE. Liver and intestine transplantation in the United States, 1995-2004. Am J Transplant. 2006; 6:1170-87
- Wilkinson A. Kidney dysfunction in the recipients of liver transplantation. Liver Transplantation 2005; 11:S47-S51.
For an extended list of references with direct article links, sign in to the Galter Health Library website at: http://www.galter.northwestern.edu/guides/expand/resident-reading-lists |
