Author: Tarun Kothari

Monkey Pox

Monkey Pox

What is Monkey pox?

Monkey pox is a contagious viral disease. The monkey pox virus is closely related to the one that causes smallpox, but the disease is generally less severe and less contagious. The World Health Organization has declared monkey pox a public health emergency of international concern, and the U.S. Department of Health and Human Services (HHS) declared a Public Health Emergency on August 4, 2022. In the United States, almost 14,000 cases have been identified in 49 states, the District of Columbia and Puerto Rico.

What are the symptoms of monkey pox?

Symptoms usually start between 5 and 13 days after a person is infected with the virus. Some people have a few days of feeling sick, similar to the flu. Symptoms might include fever, headache, feeling very tired and achy, and swollen lymph nodes. Then, a few days after these symptoms start, a rash appears.
●The monkey pox rash can look like pimples or blisters. It starts as a few small spots, then more appear.
●During the 2022 outbreak, some people have first noticed the rash in their genital or anal area.
●The rash can also affect the face, inside of the mouth, hands, feet, and other parts of the body.
●The bumps swell with fluid, then pop. Then, they dry up and form scabs, which eventually fall off.
●The rash can be painful, although it might become itchy when scabs start to form.
For some people, the rash is the first or only symptom they have, and they do not know they are sick until it appears. The rash usually lasts for about 2 to 3 weeks.

These pictures show examples of the sores that appear in people with monkeypox. They can be spread out or clustered. They start out as small spots, then swell with fluid. Eventually, they pop and form scabs, which fall off as they heal.

How does monkey pox spread?

In the past, the most common way for monkey pox to spread was from an infected animal to a person. This could happen from touching the animal’s body fluids or through a bite or scratch.
During the 2022 outbreak, the infection has been spreading from person to person. This can happen through:
●Touching an infected person’s rash, scabs, or body fluids – This seems to be the main way the infection is spreading during this outbreak. In many cases, this has happened through sexual activity. Experts are studying whether the infection can also spread through semen or vaginal fluids.
●Touching something that has touched an infected person – For example, if fluid from a person’s rash gets on clothing, bedding, or sex toys, it is possible for the infection to spread to others who touch these items.
●Through tiny droplets from the lungs – The infection can spread in this way if people are face-to-face, for example kissing or cuddling, for a long time.
It is also possible for a pregnant person to pass the infection to their baby.
A person is most likely to spread monkey pox while they have the rash. Experts do not yet know if a person is contagious before the rash appears.
Monkey pox is not as contagious as the virus that causes COVID-19. You are not likely to get it by being near someone unless you have direct contact with their skin or are face-to-face for a long time.

What is the outlook/prognosis of someone who contracts monkey pox?

Monkey pox normally takes about 2 to 4 weeks to run its course. The rash may be painful and leave scars. Most people will recover on their own and will not need hospitalization or specific treatment. A small proportion of patients, mostly those with multiple preexisting conditions or with weakened immune systems, may develop a more severe disease that could result in death. As of September 5, 2022, there have one death reported in the United States, some people have died in other countries.

There are currently no antiviral therapies approved by the Food and Drug Administration for the treatment of monkey pox; however, antiviral therapies developed against smallpox are available from the CDC as investigational drugs.

The only vaccine currently licensed against monkey pox, called JYNNEOS™, is in very short supply and is currently only available from HHS.

For some people, the rash is the first or only symptom they have, and they do not know they are sick until it appears. The rash usually lasts for about 2 to 3 weeks.

Who is at risk for monkey pox?

Anyone can get monkey pox if they have close contact with someone who is infected. During the 2022 outbreak, many of the people who have been infected are men who have sex with men. But it’s important to know that anyone can get the infection, no matter their gender identity, sexual orientation, or sex practices. Thinking of monkey pox as something that only affects certain people or groups is inaccurate and harmful.

What should I do if I have symptoms?

If you have any symptoms of monkey pox, call your doctor or nurse. They will ask you questions and schedule an exam. If possible, avoid close contact or sex with others until you have been seen by a doctor or nurse.

What should I do if I think I was exposed?

If you had close contact with someone who had monkey pox, you should also tell your doctor or nurse, even if you don’t have any symptoms. They can tell you what to do next.
If you were exposed to monkey pox, you will need to monitor yourself for symptoms for 21 days. You should then call your doctor or nurse if you notice any symptoms such as fever, swollen lymph nodes, or any rash or sores.
In some cases, experts recommend vaccination in addition to monitoring. People who might benefit from the vaccine include those who:
●Were exposed to the virus – If you recently had close contact with someone who had monkey pox, getting the vaccine might lower the chances that you will get infected. Your doctor or nurse will help you figure out if you should get the vaccine. The decision is based on how and when you were exposed.
●Are at risk for being exposed – The vaccine might be an option for people who are at high risk for getting monkey pox. For example, your risk is higher if you had a sex partner who later found out they had monkey pox. It is also higher if you have had multiple sex partners and are in an area with a lot of monkey pox cases.
The goal of vaccination is to control the current outbreak. Your doctor, nurse, or local public health office can talk to you about the vaccine and your options.

Is there a test for monkey pox?

Yes. If your doctor or nurse thinks you might have monkey pox, they will use a swab to take a sample of fluid from your rash. They will look at the sample under a microscope and send it to a special lab for testing. In some cases, they might do blood tests, too.
How is monkey pox treated?
Most people with monkey pox will not get seriously ill and will be able to stay home while they get better. This usually takes a few weeks.
In some cases, doctors might recommend treatment with “antiviral” medicines.

How can I avoid spreading monkey pox to others?

If you have monkey pox, there are things you can do to lower the risk of spreading the infection to other people.
The best way to avoid spreading the infection to others is to self-isolate:
●This means staying away from other people as much as possible, even the people you live with.
●Continue to self-isolate until your rash has fully healed. This means the scabs have fallen off and new skin has formed.
To protect others, you can also:
●Wash any clothing, bedding, or other items that have touched your rash. Do not shake out clothing or bedding around other people. If someone else needs to touch these items, or help care for you, they should wear gloves.
●Wash your hands often. Others in your home should also wash their hands often.
●Be extra careful if you do need to be around other people. Cover any parts of your skin that have a rash and wear a face mask.

How can I avoid being exposed to monkey pox?

The best way to prevent monkey pox is to avoid close contact with anyone who might have it.
To lower your risk of being exposed:
●If a family member, friend, or partner has monkey pox, they should self-isolate until their rash has healed completely.
●Avoid close contact with anyone who has symptoms of monkey pox.
●If a partner has monkey pox, avoid sex until their rash is completely healed. This includes anal, oral, or vaginal sex. Virtual or phone sex are safe ways to be intimate without physical contact.
●Using condoms any time you have sex might help. But condoms probably cannot completely prevent the spread of monkey pox. This is because it can spread in a few different ways, as discussed above.

Where can I go to learn more?

As we learn more about monkey pox, expert recommendations will continue to change.
You can find more information at the US Centers for Disease Control and Prevention (CDC) website (

Compiled courtesy of VHA and Up To Date Basic
Tarun Kothari MD,FACG,FACP

Gas and bloating :

Gas and bloating :

GAS AND BLOATING OVERVIEW Some people feel that they pass too much gas or burp too frequently, both of which can be a source of embarrassment and discomfort. The average adult produces about one to three pints of gas each day, which is passed through the anus 14 to 23 times per day. Burping occasionally before or after meals is also normal.

The amount of gas produced by the body depends upon your diet and other individual factors. However, most people who complain of excessive gas do not produce more gas than the average person. Instead, they are more aware of normal amounts of gas. On the other hand, certain foods and medical conditions can cause you to make excessive amounts of gas.

This article reviews the sources of intestinal gas, conditions that increase sensitivity to gas, and measures to reduce gas production.

SOURCES OF GAS There are two primary sources of intestinal gas: gas that is ingested (mostly swallowed air) and gas that is produced by bacteria in the colon.

Air swallowing — Air swallowing is the major source of gas in the stomach. It is normal to swallow a small amount of air when eating and drinking and when swallowing saliva. You may swallow larger amounts of air when eating food rapidly, gulping liquids, chewing gum, or smoking.

Most swallowed air is eliminated by belching so that only a relatively small amount of air passes from the stomach into the small intestine. Your posture may influence how much air passes to the small intestine.

●When sitting up, most swallowed air passes back up the esophagus and out of the mouth, which can cause you to belch.

●When lying down, swallowed air tends to pass into the small intestine, which can cause you to pass gas.

Belching may be voluntary or occur unintentionally. Involuntary belching is a normal process that typically occurs after eating to release air that enlarges or stretches the stomach. Belching is more common with certain foods that relax the ring-shaped muscle (sphincter) around the lower end of the esophagus where it joins the stomach. Such foods include peppermint, chocolate, and fats.

Bacterial production — The colon normally provides a home for billions of harmless bacteria, some of which support the health of the bowel. Certain carbohydrates are incompletely digested by enzymes in the stomach and intestines, allowing bacteria to digest them. For example, cabbage, Brussels sprouts, and broccoli contain raffinose, a carbohydrate that is poorly digested. These foods tend to cause more gas and flatulence because the raffinose is digested by bacteria once it reaches the colon. The by-products of this process include odorless gases, such as carbon dioxide, hydrogen, and methane. Minor components of gas have an unpleasant odor, including trace amounts of sulfur.

Some people are not able to digest certain carbohydrates. A classic example is lactose, the major sugar contained in dairy products. Thus, consuming large amounts of lactose may lead to increased gas production, along with cramping and diarrhea.

Lactose content of different foods:

Product                                                                                                    Lactose content (grams)

Milk (1 cup) Whole, 2%, 1%, skim                                                    9 to 14

Buttermilk                                                                                               9 to 12

Evaporated milk                                                                                    24 to 28

Sweetened condensed milk                                                                    31 to 50

Lactaid milk (lactose-reduced)                                                            3

Goat’s milk                                                                                              11 to 12

Acidophilus, skim                                                                                   11

Yogurt, low fat, 1 cup                                                                            4 to 17

Cheese, 1 ounce

Cottage cheese (1/2 cup)                                                                        0.7 to 4

Cheddar (sharp)                                                                                     0.4 to 0.6

Mozzarella (part skim, low moisture)                                                0.08 to 0.9

American (pasteurized, processed)                                                     0.5 to 4

Ricotta (1/2 cup)                                                                                     0.3 to 6

Cream cheese                                                                                          0.1 to 0.8

Butter (1 pat)                                                                                          0.04 to 0.5

Cream (1 tablespoon)

Light, whipping, sour                                                                            0.4 to 0.6

Ice cream (1/2 cup)                                                                                 2 to 6

Ice milk (1/2 cup)                                                                                    5

Sherbet (1/2 cup)                                                                                    0.6 to 2

Certain diseases can also cause excessive bloating and gas. For example, people with diabetes or scleroderma may, over time, have slowing in the activity of the small intestine. This can lead to bacterial overgrowth within the bowel, with poor digestion of carbohydrates and other nutrients. However, even in the absence of apparent disease, some people tend to harbor large numbers of bacteria in their small bowel and are prone to develop excessive gas.

GAS AND BLOATING SYMPTOMS Some people feel they pass an excessive amount of gas or burp too frequently. Other people notice bloating and crampy abdominal pain. You may feel this pain in areas where gas can become trapped. such as in bends in the colon, which occur naturally in the area under the liver (upper to mid-right part of the abdomen), and in the area under the spleen (upper to mid-left part of the abdomen).

SENSITIVITY TO GAS  The link between gas, belching, and the actual amount of gas in the intestines is not always clear. The vast majority of people who are bothered by gas-related symptoms do not have an excessive amount of gas in the intestine, but rather they have an increased sensitivity to normal amounts of gas in the intestine. This can happen in a variety of circumstances.

Irritable bowel syndrome — Many people with irritable bowel syndrome (IBS) are sensitive to normal amounts of gas. Nerves that carry messages from the bowel may be overactive in people with IBS, so that normal amounts of gas or movement in the intestines feels painful or overactive. The primary symptoms of IBS are abdominal pain and changes in bowel habits (such as diarrhea and/or constipation). Many people also complain of bloating.

Some people with severe IBS feel better when treated with medications that decrease the painful sensations coming from the intestine.

Functional dyspepsia — Dyspepsia is the term for recurrent or persistent pain or discomfort in the upper abdomen. Approximately 25 percent of people in the United States and other Western countries experience dyspepsia.

Dyspepsia can arise from various underlying conditions, the most common of which is “functional” (or “non ulcer”) dyspepsia. Functional dyspepsia causes abdominal pain without an identifiable cause, probably due to an increased sensitivity to contents within the stomach.

Irritation of the anus or esophagus — People who have irritation around their anus due to hemorrhoids or other problems may also experience more discomfort when they pass gas..

Similarly, people who have irritation of the esophagus (esophagitis) may find burping painful.

CAUSES OF INCREASED GAS The vast majority of people who are bothered by gas do not produce excessive amounts of gas. However, there are several conditions that may lead to increased gas formation.

Swallowed air — Chronic, repeated belching can occur if you swallow large amounts of air (i.e., aerophagia). Aerophagia is typically an unconscious process and is often associated with emotional stress. Treatment focuses on decreasing air swallowing by reducing anxiety, when it is considered to be a cause, as well as on eating slowly without gulping and avoiding carbonated beverages, chewing gum, and smoking.

Foods that cause gas — Certain foods contain specific carbohydrates called “FODMAPs” (fermentable oligo-, di-, and monosaccharides and polyols). FODMAPs are poorly absorbed and can result in bloating and gas production in some people. A diet that is low in FODMAPs (which are found in wheat, barley, milk, and certain fruits and vegetables, among other foods) may reduce the amount of gas you produce.

Foods commonly associated with gas and bloating:

Milk and dairy products:     Milk, ice cream, cheese (may/may not relate to lactose)

Vegetables:   Broccoli, cauliflower, Brussel sprouts, onions, leeks, parsnips, celery, radishes, asparagus, cabbage, kohlrabi, cucumber, potatoes, turnips, rutabaga

Fruits: Prunes, apricots, apples, pears, peaches, raisins, bananas

Whole grains: Wheat and oats, bagels, wheat germ, pretzels, bran/bran cereal

Legumes: Beans, peas, baked beans, soybeans, lima beans

Fatty foods: Fried foods

Liquids: Carbonated beverages, beer, carbonated medications

Miscellaneous: Chewing gum, artificial sweeteners

It’s a good idea to talk to your health care provider if you want to try limiting or avoiding certain foods. He or she can give you guidance on what to limit and how to make sure you’re still getting enough nutrients in your diet.

Starch and soluble fiber can also contribute increase gas. Potatoes, corn, noodles, and wheat produce gas, while rice does not. Soluble fiber (found in oat bran, peas and other legumes, beans, and most fruit) also causes gas. Some laxatives contain soluble fiber and may cause gas, particularly during the first few weeks of use.

Lactose intolerance — Lactose intolerance occurs when your body has difficulty digesting lactose, the sugar found in most milk-based products. Symptoms of lactose intolerance include diarrhea, abdominal pain, and flatulence after consuming milk or milk-containing products. More detailed information about lactose intolerance is available separately.

Intolerance to food sugars — Some people are intolerant of sugars contained in certain foods. Two common examples are fructose (contained in dried fruit, honey, sucrose, onions, artichokes, and many foods and drinks that contain “high fructose corn syrup”) and sorbitol (a sugar substitute contained in some sugar-free candies and chewing gum).

Diseases associated with increased gas — A number of diseases can cause difficulty absorbing carbohydrates, which can lead to increased gas. This problem can occur in people with celiac disease (a disease caused by intolerance to a protein contained in wheat), short bowel syndrome, and in some rare disorders.

GAS AND BLOATING DIAGNOSIS Most people with gas and bloating do not need to have any testing. However, symptoms such as diarrhea, weight loss, abdominal pain, anemia, blood in the stool, lack of appetite, fever, or vomiting can be warning signs of a more serious problem; people with one or more of these symptoms usually require testing.

Tests may include:

●Examination of stool for blood, abnormally high levels of fat (steatorrhea), or a parasite (e.g., Giardia).

●A lactose tolerance test

●X-ray examination of the small intestine.

●A test to examine the inside of the stomach and/or colon (upper endoscopy, sigmoidoscopy, or colonoscopy).

●A blood test for celiac disease.

GAS AND BLOATING TREATMENT Several measures can help to reduce bothersome gas.

Diet recommendations — Avoid foods that appear to aggravate your symptoms. These may include milk and dairy products, certain fruits or vegetables, whole grains, artificial sweeteners, and/or carbonated beverages. Keep a record of foods and beverages to help to pinpoint which foods are bothersome.

If you are lactose intolerant, do not consume products that contain lactose or you can use a lactose-digestive aid such as lactose-reduced milk or over-the-counter lactase supplements (e.g., Lactaid tablets or liquid). Take a calcium supplement if you avoid milk products. Avoiding foods high in fructose will help if you have fructose intolerance.

Over-the-counter medications — Try an over-the-counter product that contains simethicone, such as certain antacids (e.g., Maalox Anti-Gas, Mylanta Gas, Gas-X, Phazyme). Simethicone causes gas bubbles to break up and is widely used to relieve gas, although its benefit is questionable.

Try an over-the-counter product that contains activated charcoal (e.g., Charco Caps, CharcoAid). The benefit of activated charcoal is unclear, although it is reasonable to try.

Try Beano, an over-the-counter preparation that helps to breakdown certain complex carbohydrates. This treatment may be effective in reducing gas after eating beans or other vegetables that contain raffinose.

Try bismuth subsalicylate (e.g., Pepto-Bismol) to reduce the odor of unpleasant-smelling gas.

Deodorizing products — Consider a device to deodorize gas, such as underwear made from carbon fiber (e.g., Under-Ease protective underwear and Gas Medic under air brief). These appear to be effective but are expensive. Charcoal-lined cushions or pads are also available but may not be as effective.

Compiled and organized, courtesy UpToDate

Tarun Kothari MD

Cirrhosis Of Liver

Cirrhosis Of Liver


Cirrhosis is a disease in which the liver becomes severely scarred, usually as a result of many years of continuous injury. The most common causes of cirrhosis include alcohol abuse, chronic hepatitis B or C (viral infections that affect the liver), and fatty liver disease (often seen in people with obesity or diabetes). In its advanced stages, cirrhosis is usually irreversible, so treatment may involve liver transplant. In its earlier stages, cirrhosis may be reversible if the underlying cause can be treated.


The liver is a large organ (weighing about three pounds) that is located in the right upper abdomen beneath the rib cage. It performs many functions that are essential to life. The liver is able to repair itself when it has been injured. However, the process of healing involves the creation of scar tissue. Thus, repeated or continuous injury to the liver (such as occurs with heavy alcohol use) can cause significant scarring in the liver. The body is able to tolerate a partially scarred liver without serious consequences. Eventually, the scarring can become so severe that the liver is no longer able to perform its normal functions.

There are many forms of liver disease that can lead to cirrhosis. In the United States, the two most common causes of cirrhosis are alcoholic liver disease and hepatitis C, which together account for roughly half of the people awaiting a liver transplant.

In developed countries, common causes of cirrhosis include the following, but many other causes also exist:

●Longstanding alcohol abuse

●Chronic hepatitis (B or C))

●Nonalcoholic steatohepatitis)

●Hemochromatosis (a condition that causes iron to build up in the liver)


People with cirrhosis sometimes have no symptoms, but the condition can cause a long list of possible signs and symptoms, not all of which occur together. Some of the more common symptoms include:

●Loss of appetite

●Weight loss


●Jaundice (yellowing of the skin or eyes)


●Signs of upper gastrointestinal bleeding (such as vomiting blood, or having bowel movements that look like tar or that contain blood)

●Swelling in the abdomen (caused by a condition called ascites, in which fluid builds up around the organs in the abdomen)

●Mood changes, confusion, or abnormal sleep patterns (caused by a condition called hepatic encephalopathy)

●Muscle cramps, which can be severe

●Absent or irregular menstrual bleeding (in women)

●Erectile dysfunction, infertility, or loss of sex drive (in men)

●Breast development in men

●Spider veins

Portal hypertension — Cirrhosis can cause a problem called portal hypertension, which is when the blood pressure inside the portal vein, the main source of blood for the liver, gets too high. This happens because scars in the liver obstruct blood flow through the organ. As the pressure builds up, blood backs up into nearby blood vessels, primarily in and around the esophagus and intestines.

Changes in the hands — Cirrhosis can affect the hands, causing the palms to redden, the nails to whiten or develop white stripes, and the tips of the fingers to widen. It can also cause a condition called Dupuytren’s contracture, in which tissues in the hand shrink and harden, ultimately limiting the mobility of certain fingers.

Blood abnormalities — People with cirrhosis often have a number of abnormalities in their blood. For example, they can have abnormal levels of certain proteins and enzymes, and their blood may not clot as well as it should. Plus, they do not always have enough of certain blood cells.


If a healthcare provider suspects cirrhosis, they will usually order an imaging test of the abdomen, most often an ultrasound. The healthcare provider might also order a liver biopsy, which involves using a needle to get a sample of liver tissue so it can be examined for signs of damage. A biopsy may not be necessary if the symptoms, blood tests, and imaging tests all point to cirrhosis.

An alternative method for diagnosing cirrhosis is a test called Fibroscan, which uses ultrasound to measure liver stiffness. This measurement can then be used to estimate how much scarring there is in the liver and to determine if cirrhosis has developed.


When treating people with cirrhosis, healthcare providers have the following major goals in mind, each of which is discussed in more detail below:

●Slow or reverse the cause of the liver disease

●Prevent, identify, and treat the complications of cirrhosis

●Protect the liver from other sources of damage

●Manage symptoms and blood abnormalities

●Determine if and when a liver transplant is needed


The first part of treatment for cirrhosis involves identifying its underlying cause and treating that, if possible. For example, if a person’s cirrhosis is due to alcoholism, it’s imperative to get the alcohol use treated and under control. Likewise, if a person’s cirrhosis is caused by an infection, such as hepatitis C, it’s important to treat the infection.

Some of the causes of liver disease that can lead to cirrhosis are discussed elsewhere. See:


When it is healthy, the liver has many jobs, among them to filter toxins out of the blood, break down certain drugs and alcohol, and make proteins that are important in clotting or digestion. Cirrhosis can lead to many complications, some of which happen because the liver is no longer able to do these jobs well, and some of which happen because blood flow through the liver is disrupted.

The major complications of cirrhosis are described below.

Esophageal varices and variceal hemorrhage — Esophageal varices are dilated blood vessels in the esophagus. These blood vessels swell because the blood flow through the liver is blocked by all the scarring, causing blood to back up into the veins in the esophagus and stomach. When the pressure gets too high inside these blood vessels, they can burst and cause severe bleeding (also called variceal hemorrhage).

The main symptoms of variceal hemorrhage are vomiting blood or having bowel movements that contain blood or that look like tar (which indicates the presence of blood in the stool).

Ascites (abdominal swelling) — For reasons that are not entirely understood, people with cirrhosis sometimes accumulate fluid in the abdomen. This condition, called ascites, causes the abdomen to swell. Ascites can also cause a person to feel short of breath or full. To treat ascites, healthcare providers prescribe medications called diuretics, which help the body excrete excess fluid. They also recommend that people with the condition reduce the amount of sodium they consume.

In extreme cases, healthcare providers will drain fluid from the abdomen using a technique called paracentesis. They can also put in a tube that goes through the liver called a trans jugular intrahepatic portosystemic shunt (TIPS). The tube allows blood to bypass the liver, which relieves some of the pressure that builds up because of the scarring in the liver.

Infections of the abdominal cavity — People with ascites sometimes develop an infection of the fluid, known as spontaneous bacterial peritonitis. These infections do not always cause symptoms, but when they do, symptoms can include fever, abdominal pain or tenderness, and confusion or grogginess. Healthcare providers diagnose these infections by draining some of the fluid in the abdomen with a needle and checking it for bacterial growth and white blood cells (which are involved in fighting infection). Treatment involves strong antibiotics and diuretics to reduce fluid buildup in the abdomen. People with these infections sometimes also have to stop taking medications called proton pump inhibitors, such as Omeprazole (sample brand name: Prilosec), which are used to treat acid reflux. These medications stop the production of stomach acid. Since stomach acid is one of the ways the body protects itself from bacteria, people with ascites who take these medications are at increased risk of infection.

Hepatic encephalopathy — For reasons that are not entirely clear, cirrhosis can adversely affect brain function. One explanation is that toxins build up in the blood when the liver is malfunctioning, possibly interfering with normal brain processes. Hepatic encephalopathy is the medical term for the disruption in brain function caused by liver disease. It can manifest as sleep disturbances (sleeping too much, too little, or sleeping during the day); mood or personality changes; trouble concentrating or thinking clearly; shaking; or slurred speech.

Hepatic encephalopathy can sometimes be treated and normal brain function restored. Treatment involves getting other stressors, such as infections and bleeding under control, or taking certain medicines, such as Lactulose (which will cause softening of the stool) or an antibiotic called Rifaximin (brand name: Xifaxan).

Hepatorenal syndrome — Hepatorenal syndrome is a form of kidney disease that results from cirrhosis. It happens in part because the interrupted blood flow through the liver restricts blood flow to the kidneys.

Hepatorenal syndrome does not necessarily cause symptoms, though it can cause some people to urinate less than usual. The condition is detected with blood and urine tests. Hepatorenal syndrome is treated by trying to improve liver function (for example, stopping alcohol or treating hepatitis B). If the liver function cannot be improved, liver transplantation is often needed.

Lung and heart complications — Cirrhosis and the related problems it causes with circulation can lead to a number of problems with the lungs and heart. When these organs are affected, people can have fatigue, trouble breathing, chest pain, and other symptoms.

Liver cancer — People with cirrhosis have an increased risk of developing liver cancer, especially if their cirrhosis was caused by hepatitis B, hepatitis C, nonalcoholic steatohepatitis, or hemochromatosis. Given this elevated risk, people with cirrhosis should have an ultrasound every six months to check for signs of cancer.

When liver cancer first develops, it often causes no symptoms of its own. As it progresses, it can either exacerbate the complications of cirrhosis or cause symptoms such as pain, feeling full quickly, and jaundice. Some people with liver cancer from cirrhosis are treated with a liver transplant, which removes the cancer. People who may be candidates for a liver transplant include those with small cancers that have not spread outside of the liver.


People with cirrhosis have to be extra careful about protecting their liver from anything besides their liver disease that could harm their liver. Steps to protect the liver from further damage are described below.

Vaccines to protect the liver — Vaccines against hepatitis A and B for those who are not already immune can help prevent further damage to the liver. Because infections can be especially hard on people with cirrhosis, it’s also important to get other vaccines, including vaccines to protect against the flu (once a year), pneumonia (at least once), diphtheria and tetanus (once every 10 years), and pertussis (once during adulthood.)

Avoid alcohol and other drugs that could harm the liver — People with cirrhosis should avoid all substances that are known to damage the liver. This includes:


●Nonsteroidal anti-inflammatory drugs, such as Ibuprofen (sample brand names: Advil, Motrin) and Naproxen (sample brand name: Aleve)

●Some supplements and herbal remedies, such as Kava Kava

●Some prescribed medications

Also, people with cirrhosis who take Acetaminophen (sample brand name: Tylenol) should not take more than 2,000 milligrams per day (four extra-strength tablets). Many over-the-counter and prescription medications to treat cold and flu, fever, pain, and other common maladies contain acetaminophen, so it’s important to check the labels of any medications for acetaminophen as an ingredient and to add up the milligrams they each contain.

Take the right medication doses for someone with liver disease — Aside from needing to avoid certain medications and substances, people with cirrhosis sometimes need to take less of certain medications than people with healthy livers. That’s because one of the jobs of the liver is to break down medications and clear them out of the blood. When the liver is not working well, those medications can build up in the body and become toxic.

Separately, some medications can have side effects that worsen the complications of cirrhosis. Medications called benzodiazepines (sample brand names: Valium, Klonopin, Xanax), for example, which are used to ease anxiety, can worsen hepatic encephalopathy.

To find out if anything you take could harm your liver, put all the bottles of all the medications you take into a bag and take them with you to the doctor who manages your liver disease. Include all over-the-counter medications, supplements, and herbal drugs, as well as any prescriptions you take. Never start any new medications or supplements without first checking with your doctor. Also, any time you are being prescribed a new medication, make sure the healthcare provider prescribing it knows about your liver disease.


People with cirrhosis sometimes develop symptoms related to their disease that are distinct from the complications discussed above. They also sometimes have blood abnormalities that require treatment.

Muscle cramps — People with cirrhosis sometimes get muscle cramps, which can be severe. There are few treatments for cramps, including a medicine called Quinine, which is hard to get in the United States because of concerns about serious side effects, such as irregular heartbeats. You should not start quinine without first discussing it with a healthcare provider.

Umbilical hernias — An umbilical hernia is a swelling or bulge that forms at the belly button. This type of hernia happens when the tough layer of tissue that normally contains the abdominal organs—called the abdominal wall—becomes weak. As the abdominal wall gives way, the contents of the abdomen start to push through, creating a bulge. Sometimes doctors can gently ease the tissues that bulge through the hernia back into the abdomen (this is called reducing the hernia). But if the tissue that bulges out through the hernia gets squeezed too tightly, it can get cut off from its blood supply and begin to die (this is called incarceration).

Umbilical hernias can be repaired with surgery, but people with cirrhosis can often have serious complications with surgery, and the surgery does not always fix the problem. As a result, doctors are often hesitant to recommend surgery unless there is a serious incarceration. Except when it is urgently needed, doctors often suggest waiting and doing hernia repair at the same time as a liver transplant.

Hyponatremia (too little sodium) — Hyponatremia is the medical term for “too little sodium in the blood.” People with advanced cirrhosis commonly develop hyponatremia, and it can be serious.

Sodium is one of many substances called electrolytes that help carry electrical signals between cells. That’s important because many cells rely on electrical signals to function normally. Sodium also helps keep the right amount of fluid inside cells. Maintaining the right concentration of sodium in the body is important. Unfortunately, restoring normal sodium levels in people with cirrhosis and hyponatremia is difficult to do. Often hyponatremia heralds the need for a liver transplant.

Blood clotting problems — The blood of people with cirrhosis often does not clot as it should. That’s because the liver is responsible for making many of the proteins and other substances that orchestrate the formation of clots. This is a problem, because it puts people with cirrhosis at risk of serious bleeding, particularly if they also have esophageal varices. Because treating the problem involves a type of blood transfusion, doctors usually only do so if the person is about to undergo a surgery or procedure that could cause bleeding.

Some people have problems with too much clotting, which can lead to clots forming where they are not needed. A common place for this to occur is in the large vein that leads to the liver (called the portal vein). Clots in the portal vein can make portal hypertension worse and may lead to the development of new varices in the esophagus or stomach.


Liver transplant involves replacing a diseased liver with a healthy liver. It is the definitive treatment for people with advanced cirrhosis. Still, not everyone with advanced cirrhosis is a good candidate for a transplant. Some of the reasons why people might not be good candidates include liver cancer that has spread outside the liver, or significant heart or lung disease. Liver transplant is a complicated, major surgery, so people undergoing the surgery need to be healthy enough to survive the surgery and recovery. What’s more, even people who are good candidates must wait for a compatible liver to be available.

The waiting list for a liver transplant is lengthy (up to two years in some regions), so it is important for people to find out as early as possible (while they are still relatively healthy) if a liver transplant is a reasonable option. The majority of donated livers come from people who have suffered brain death for one reason or another. More recently, living donors have been able to donate a portion of their liver.

More than 80 percent of people will be alive one year after a liver transplant, and the majority of these will be alive five years after the transplant. This is compared with an extremely high death rate in patients with very advanced cirrhosis who do not receive a liver transplant.

The prognosis after a liver transplant depends in part on the underlying cause of the liver disease, some of which recur following the transplant. For example, most people who undergo a transplant for hepatitis C will develop recurrent hepatitis C after the transplant.

Other major concerns following a transplant are the risks of anti-rejection drugs used to suppress the immune system, which have many side effects, and the risk of rejection of the transplanted organ.

Treatment centers that perform liver transplants can be found at the Organ Procurement and Transplantation Network (OPTN) website.

Tarun Kothari MD, FACG, FACP

Compiled from Up To Date patient’s basics education.



Patient education: Influenza symptoms and treatment:

INTRODUCTION Influenza (commonly called the flu) is a highly contagious illness that can occur in children or adults of any age. It occurs more often in the winter months because people spend more time in close contact with one another. The flu is spread easily from person to person by coughing, sneezing, or touching surfaces.

Every year, complications of the flu require more than 200,000 people in the United States to be hospitalized. Serious illness is more likely in the very young, older adults, pregnant women, and people who have certain health problems such as asthma or other forms of lung disease.

There have been several widespread flu outbreaks (called pandemics), which led to the deaths of many people worldwide. These outbreaks occurred when new strains of influenza viruses formed (often from pigs or birds) and humans became infected because they had no immunity to these viruses.

FLU SYMPTOMS Symptoms of seasonal flu can vary from person to person but usually include:

●Fever (temperature higher than 100ºF, or 37.8ºC)

●Headache and muscle aches


●Cough and sore throat may also be present

People with the flu usually have a fever for two to five days. This is different than fever caused by other upper respiratory viruses, which usually resolve after 24 to 48 hours.

Most people with the flu have fever and muscle aches, and some people also have cold-like symptoms (runny nose, sore throat). Flu symptoms usually improve over two to five days, although the illness may last for a week or more. Weakness and fatigue may persist for several weeks.

Flu complications — Complications of influenza occur in some people; pneumonia is the most common complication. Pneumonia is a serious infection of the lungs and is more likely to occur in young children, people over the age of 65, people who live in long-term care facilities (nursing homes), and those with other illnesses such as diabetes or conditions affecting the heart or lungs. Pneumonia is also more common in people with weakened immune systems, such as those who have had a transplant. 

Is it a cold or the flu?

FeverRareUsual; high (100°F to 102°F; occasionally higher, especially in young children); lasts 3 to 4 days
General aches, painsSlightUsual; often severe
Fatigue, weaknessSometimesUsual; can last up to 2 to 3 weeks
Extreme exhaustionNeverUsual; at the beginning of the illness
Stuffy noseCommonSometimes
Sore throatCommonSometimes
Chest discomfort, coughMild to moderate; hacking coughCommon; can become severe

Reproduced from: National Institutes of Health. (

FLU DIAGNOSIS Influenza is usually diagnosed based on symptoms (fever, cough, and muscle aches). Lab testing for influenza is performed in certain cases, such as during a new influenza outbreak in a community and in patients who are at increased risk for complications.


When to seek help — Most people with the flu recover within one to two weeks without treatment. However, serious complications of the flu can occur. Call your doctor or nurse immediately if:

●You feel short of breath or have trouble breathing

●You have pain or pressure in your chest or stomach

●You have signs of being dehydrated, such as dizziness when standing or not passing urine

●You feel confused

●You cannot stop vomiting or you cannot drink enough fluids

In children, you should seek help if the child has any of the above or if the child:

●Has blue or purplish skin color

●Is so irritable that he or she does not want to be held

●Does not have tears when crying (in infants)

●Has a fever with a rash

●Does not wake up easily

There are several groups of people who are at increased risk for flu complications. These include pregnant women, young children (<5 years of age and especially <2 years of age), people ≥65 years of age, and people with certain diseases such as chronic lung disease (such as asthma), heart disease, diabetes, immunosuppressing conditions (such as HIV infection or transplantation), and some other diseases. If you or your child has flu symptoms and is at increased risk for flu complications, you should call your health care provider.

Treat symptoms — Treating the symptoms of influenza can help you to feel better but will not make the flu go away faster.

●Rest until the flu is fully resolved, especially if the illness has been severe.

●Fluids – Drink enough fluids so that you do not become dehydrated. One way to judge if you are drinking enough is to look at the color of your urine. Normally, urine should be light yellow to nearly colorless. If you are drinking enough, you should pass urine every three to five hours.

Acetaminophen (sample brand name: Tylenol) can relieve fever, headache, and muscle aches. Aspirin and medicines that include aspirin (eg, bismuth subsalicylate [sample brand name: Pepto-Bismol]) are not recommended for children under 18 because aspirin can lead to a serious disease called Reye syndrome.

●Cough medicines are not usually helpful; cough usually resolves without treatment. We do not recommend cough or cold medicine for children under age 6 years.

Antiviral treatment — Antiviral medicines can be used to treat or prevent influenza. When used as a treatment, the medicine does not eliminate flu symptoms, although it can reduce the severity and duration of symptoms by about one day. Not every person with influenza needs an antiviral medicine, but some people do; the decision is based upon several factors. If you are severely ill and/or have risk factors for developing complications of influenza, you will need an antiviral agent. People who are only mildly ill and have no risk factors for complications are usually treated with an antiviral medicine if they have had symptoms for 48 hours or less, but they are not treated if they have had symptoms for more than 48 hours.

Antiviral medicines that are used to treat the flu include oseltamivir (brand name: Tamiflu), zanamivir (brand name: Relenza), peramivir (brand name: Rapivab), and baloxavir (brand name: Xofluza). Antiviral treatment is most effective for seasonal influenza when it is taken within the first 48 hours of flu symptoms.

The best antiviral medicine depends upon the type of influenza virus, if the virus could be resistant, and some individual factors. A doctor or nurse should make this decision.

Side effects — Zanamivir and oseltamivir can cause mild side effects, including nausea and vomiting; zanamivir, which is inhaled, can cause difficulty breathing in some cases. Diarrhea is the most common side effect of peramivir and baloxavir. Most people are able to continue the medicine despite the side effects.

Antibiotics — Antibiotics are NOT useful for treating viral illnesses such as influenza. Antibiotics should only be used if there is a bacterial complication of the flu such as bacterial pneumonia, ear infection, or sinusitis. Antibiotics can cause side effects and lead to development of antibiotic resistance.

Complementary and alternative treatments — There are a wide variety of herbal, homeopathic, and other complementary and alternative treatments that are marketed for influenza. Unfortunately, there have been few well-designed studies to evaluate their efficacy and safety.

SWINE H1N1 FLUA new strain of H1N1 influenza, which contains parts of swine, avian, and human influenza viruses, was first seen in humans in March 2009 in Mexico. Human infections subsequently occurred around the world and caused a pandemic that continued until August 2010. The same strain of H1N1 influenza has since become one of the strains of seasonal influenza.

Symptoms of infection with the swine H1N1 flu virus and treatment for it were generally similar to those of seasonal flu.

AVIAN FLU Avian influenza (bird flu) is caused by strains of influenza virus that originally infected birds. Infected birds include chickens, ducks, and geese, among others.

There are several strains of avian flu; the H5N1 avian flu virus is the cause of concern since it has led to several deaths in people, mostly in Asia. Another type of avian flu that causes illness in people is called H7N9. To date, avian flu has primarily spread from bird to bird and much less commonly from bird to human; human-to-human transmission has occurred rarely. Most humans who became infected with avian flu had direct contact with sick or dead poultry or wild birds or had very recently visited a live poultry market. No human cases of avian influenza have been described in the United States or elsewhere in North America.

Avian flu is frequently severe, and there is little natural immunity in the human population. At least one antiviral medicine (oseltamivir) might improve the chance of surviving the infection.

There is a vaccine to prevent H5N1 avian flu. The vaccine is not commercially available but has been stockpiled by the United States government in case it is needed in the future.

Compiled from Up To Date Basics

Tarun Kothari MD, FACG

COVID-19 Patient Education-Basic

COVID-19 Patient Education-Basic

Patient education: COVID-19 overview:

What is COVID-19?COVID-19 stands for “coronavirus disease 2019.” It is caused by a virus called SARS-CoV-2. The virus first appeared in late 2019 and quickly spread around the world.
What are the symptoms of COVID-19?Symptoms usually start 4 or 5 days after a person is infected with the virus. But in some people, it can take up to 2 weeks for symptoms to appear. Some people never show symptoms at all.
When symptoms do happen, they can include:
●Trouble breathing
●Feeling tired
●Shaking chills
●Muscle aches
●Sore throat
●Problems with sense of smell or taste
Some people have digestive problems like nausea or diarrhea. There have also been some reports of rashes or other skin symptoms. For example, some people with COVID-19 get reddish-purple spots on their fingers or toes. But it’s not clear why or how often this happens.
For most people, symptoms will get better within a few weeks. But a small number of people get very sick and stop being able to breathe on their own. In severe cases, their organs stop working, which can lead to death.
Some people with COVID-19 continue to have some symptoms for weeks or months. This seems to be more likely in people who are sick enough to need to stay in the hospital. But this can also happen in people who did not get very sick. Doctors are still learning about the long-term effects of COVID-19.
While children can get COVID-19, they are less likely than adults to have severe symptoms.

Am I at risk for getting seriously ill?

It depends on your age and health. In some people, COVID-19 leads to serious problems like pneumonia, not getting enough oxygen, heart problems, or even death. This risk gets higher as people get older. It is also higher in people who have other health problems like serious heart disease, chronic kidney disease, type 2 diabetes, chronic obstructive pulmonary disease (COPD), sickle cell disease, or obesity. People who have a weak immune system for other reasons (for example, HIV infection or certain medicines), asthma, cystic fibrosis, type 1 diabetes, or high blood pressure might also be at higher risk for serious problems.

How is COVID-19 spread?

The virus that causes COVID-19 mainly spreads from person to person. This usually happens when an infected person coughs, sneezes, or talks near other people. The virus is passed through tiny particles from the infected person’s lungs and airway. These particles can easily travel through the air to other people who are nearby. In some cases, like in indoor spaces where the same air keeps being blown around, virus in the particles might be able to spread to other people who are farther away.
The virus can be passed easily between people who live together. But it can also spread at gatherings where people are talking close together, shaking hands, hugging, sharing food, or even singing together. Eating at restaurants raises the risk of infection, since people tend to be close to each other and not covering their faces. Doctors also think it is possible to get infected if you touch a surface that has the virus on it and then touch your mouth, nose, or eyes. However, this is probably not very common.
A person can be infected, and spread the virus to others, even without having any symptoms.

Are there different variants of the virus that causes COVID-19?

Yes. Viruses constantly change or “mutate.” When this happens, a new strain or “variant” can form. Most of the time, new variants do not change the way a virus works. But when a variant has changes in important parts of the virus, it can act differently.
Experts have discovered several new variants of the virus that causes COVID-19. Certain variants seem to spread more easily than the original virus. They might also make people sicker.
Experts are studying the different variants. This will help them better understand how far they have spread, whether they affect people differently, and how well different vaccines protect against them.
The more people who get vaccinated against COVID-19, the harder it will be for the virus to form new variants.

Is there a test for the virus that causes COVID-19?

Yes. If your doctor or nurse suspects you have COVID-19, they might take a swab from inside your nose or mouth for testing. In some cases, they might take a sample of your saliva. These tests can help your doctor figure out if you have COVID-19 or another illness.
There are 2 types of tests used to diagnose COVID-19:
●Molecular tests – These look for the genetic material from the virus. They are also called “nucleic acid tests.” You can get a molecular test at a doctor’s office, clinic, or pharmacy. There are also places that make these tests available for lots of people, often at drive-through locations. Depending on the lab, it can take up to several days to get test results back.
Molecular tests are the best way to know if a person has COVID-19. That’s because they can detect even very low levels of virus in the body.
●Antigen tests – These look for proteins from the virus. They can give results faster than most molecular tests. You can do an antigen test at a doctor’s office, clinic, pharmacy, or through some organizations that make testing available in other places. You can also do an antigen test at home.
Antigen tests are not as accurate as molecular tests. They are more likely to give “false negative” results. This is when the test comes back negative even though the person actually is infected. But antigen tests can still be useful in some situations, when results are needed quickly, or a molecular test is not available. For example, if a person has early symptoms of COVID-19, an antigen test can be accurate enough to detect virus in their body. If a person gets an antigen test and the result is negative, a molecular test might be needed to confirm they do not have the virus in their body. This might be done if the person has symptoms or knows they were exposed the virus.
There is also a blood test that can show if a person has had COVID-19 in the past. This is called an “antibody” test. Antibody tests are generally not used on their own to diagnose COVID-19 or make decisions about care. But experts can use them to learn how many people in a certain area were infected without knowing it.

Can COVID-19 be prevented?

The best way to prevent COVID-19 is to get vaccinated. In the United States, the first vaccines became available in late 2020. People age 5 and older can get a vaccine.
If enough people get the vaccine, the virus will stop spreading so quickly.
Experts believe that vaccines will be one of the most important ways to control the COVID-19 pandemic. People who are fully vaccinated are at much lower risk of getting the virus.
If you are not yet vaccinated, there are other ways to help protect yourself and others:
●Practice “social distancing.” It’s most important to avoid contact with people who are sick. But social distancing also means staying at least 6 feet (about 2 meters) from anyone outside your household. That’s because the virus can spread easily through close contact, and it’s not always possible to know who is infected.
●Wear a face mask when you need to go be in public around other people. This is mostly so that if you are infected, even if you don’t have any symptoms, you are less likely to spread the infection to other people. It might also help protect you from others who could be infected. Make sure your mask covers your mouth and nose.
You can buy cloth masks and disposable (non-medical) masks in stores or online. Cloth masks work best if they have several layers of fabric. Your mask should fit snugly over your face with no gaps. You can improve the fit by using a mask with an adjustable nose wire, adjusting, or knotting the ear loops to make it tighter, or wearing a cloth mask on top of a disposable mask.
When you take your mask off, make sure you do not touch your eyes, nose, or mouth. And wash your hands after you touch the mask. You can wash cloth masks with the rest of your laundry.
When you are outdoors and not around other people, you might not need to wear a mask. But it’s important to know what the rules are in your area. The United States Centers for Disease Control and Prevention (CDC) has more information about how to wear a face mask:
●Wash your hands with soap and water often. This is especially important after being out in public or touching surfaces that many other people also touch, like door handles or railings. The risk of getting infected by touching items like this is probably not very high. Still, it’s a good idea to wash your hands often. This also helps protect you from other illnesses, like the flu or the common cold.
Make sure to rub your hands with soap for at least 20 seconds, cleaning your wrists, fingernails, and in between your fingers. Then rinse your hands and dry them with a paper towel you can throw away. If you are not near a sink, you can use a hand sanitizing gel to clean your hands. The gels with at least 60 percent alcohol work the best. But it is better to wash with soap and water if you can.
●Avoid touching your face, especially your mouth, nose, and eyes.
●Avoid or limit traveling if you can. Any form of travel, especially if you spend time in crowded places like airports, increases your risk of getting and spreading infection.
If you do need to travel, be sure to check whether there are any rules about COVID-19 in the area you are visiting. In the United States, some places require people to “self-quarantine” for some length of time if they are visiting (or returning) from another state. This means not going out in public or being around other people. The United States also requires a negative COVID-19 test for anyone who enters, or returns to, the country. Many other countries have testing requirements for visiting, too. All of these rules are meant to help slow the spread of COVID-19.
Once you are fully vaccinated, you are much less likely to get the virus. “Fully vaccinated” means you have had all doses of the vaccine and it has been at least 2 weeks since the last dose. (If you had a single-dose vaccine, you are fully vaccinated 2 weeks after you get the shot.)

What should I do if I have symptoms?

If you have a fever, cough, trouble breathing, or other symptoms of COVID-19, call your doctor or nurse. They will ask about your symptoms. They might also ask about any recent travel and whether you have been around anyone who might have been infected. Then they can tell you if you should come in or go somewhere else to be tested.
If your symptoms are not severe, it is best to call before you go in. The staff can tell you what to do and whether you need to be seen in person. Many people with only mild symptoms should stay home and avoid other people until they get better. If you do need to go to the clinic or hospital, be sure to wear a mask. This helps protect other people. The staff might also have you wait someplace away from other people.
If you are severely ill and need to go to the clinic or hospital right away, you should still call ahead if possible. This way the staff can care for you while taking steps to protect others. If you think you are having a medical emergency, call for an ambulance

What if I feel fine but think I was exposed?

If you think you were in close contact with someone with COVID-19, what to do next depends on whether you have already had COVID-19 or gotten the vaccine:
●If you have not had COVID-19 or gotten the vaccine – You should get tested after a possible exposure, even if you don’t have any symptoms. Call your doctor or nurse if you aren’t sure where to get a test. Then self-quarantine at home and monitor yourself for symptoms. This means staying home as much as possible and staying at least 6 feet (2 meters) away from other people in your home.
The safest thing to do after a possible exposure is to self-quarantine for 14 days. This can be challenging with work, school, or other responsibilities. Because of this, some public health departments might allow people to stop quarantining sooner, especially if they get a negative test. If you’re not sure how long to quarantine for, contact your local public health office or ask your doctor or nurse.
●If you have had COVID-19 or gotten the vaccine – If you had COVID-19 within the last 3 months, you do not need to self-quarantine. If you had COVID-19 but it was more than 3 months ago, follow the steps above.
If you are fully vaccinated, you do not need to self-quarantine. But you should still get tested 3 to 5 days after you were in contact with the person who had COVID-19. Even though you are much less likely to get the infection after being vaccinated, it is still possible.
If you self-quarantine for less than 14 days, or if you do not need to self-quarantine, you should still monitor yourself for symptoms for the full 14 days. If you start to have any symptoms, call your doctor or nurse right away. You should also be extra careful about wearing a mask and social distancing during this time.

How is COVID-19 treated?

Many people will be able to stay home while they get better. But people with serious symptoms or other health problems might need to go to the hospital.
●Mild illness – Mild illness means you might have symptoms like fever and cough, but you do not have trouble breathing. Most people with COVID-19 have mild illness and can rest at home until they get better. This usually takes about 2 weeks, but it’s not the same for everyone.
If you are recovering from COVID-19, it’s important to stay home and “self-isolate” until your doctor or nurse tells you it’s safe to stop. Self-isolation means staying apart from other people, even the people you live with. When you can stop self-isolation will depend on how long it has been since you had symptoms, and in some cases, whether you have had a negative test (showing that the virus is no longer in your body).
●Severe illness – If you have more severe illness with trouble breathing, you might need to stay in the hospital, possibly in the intensive care unit (also called the “ICU”). While you are there, you will most likely be in a special isolation room. Only medical staff will be allowed in the room, and they will have to wear special gowns, gloves, masks, and eye protection.
The doctors and nurses can monitor and support your breathing and other body functions and make you as comfortable as possible. You might need extra oxygen to help you breathe easily. If you are having a very hard time breathing, you might need a breathing tube. The tube goes down your throat and into your lungs. It is connected to a machine to help you breathe, called a “ventilator.”
Doctors are studying several possible treatments for COVID-19. In certain cases, they might recommend treatments called “monoclonal antibodies.” These treatments seem to help some people who are at risk of getting severely ill. Doctors also might recommend being part of a clinical trial. A clinical trial is a scientific study that tests new medicines to see how well they work. Do not try any new medicines or treatments without talking to a doctor.
What should I do if someone in my home has COVID-19?If someone in your home has COVID-19, there are additional things you can do to protect yourself and others:
●Keep the sick person away from others – The sick person should stay in a separate room and use a different bathroom if possible. They should also eat in their own room.
Experts also recommend that the person stay away from pets in the house until they are better.
●Have them wear a mask – The sick person should wear a mask when they are in the same room as other people. If they can’t wear a mask, you can help protect yourself by covering your face when you are in the room with them.
●Wash hands – Wash your hands with soap and water often.
●Clean often – Here are some specific things that can help:
•Wear disposable gloves when you clean. It’s also a good idea to wear gloves when you have to touch the sick person’s laundry, dishes, utensils, or trash. Wash your hands after removing your gloves.
•Regularly clean things that are touched a lot. This includes counters, bedside tables, doorknobs, computers, phones, and bathroom surfaces.
•Clean things in your home with soap and water, but also use disinfectants on appropriate surfaces. Some cleaning products work well to kill bacteria, but not viruses, so it’s important to check labels. The United States Environmental Protection Agency (EPA) has a list of products here:

If I am pregnant and get infected, can I pass the virus to my baby?

Experts think it might be possible for a baby to get the infection while still in the uterus. But this seems to be very uncommon. And when it does happen, most babies do not get very sick.
It is also possible to pass the virus to the baby during childbirth or after the baby is born. If you have COVID-19 when you give birth, there are ways to lower this risk.

Can COVID-19 cause problems with pregnancy?

From what experts know so far, most people who get COVID-19 during pregnancy will not have serious problems. But problems can happen if the mother becomes seriously ill.
Pregnant people who get COVID-19 might have an increased risk of preterm birth. This is when the baby is born before 37 weeks of pregnancy. This seems to be more of a risk in people who get very sick and have pneumonia. Preterm birth can be dangerous, because babies who are born too early can have serious health problems.
If you are pregnant and you have questions about COVID-19, talk to your doctor, nurse, or midwife. They can help.

What can I do to cope with stress and anxiety?

It’s normal to feel anxious or worried about COVID-19. It’s also normal to feel stressed, lonely, or tired of not being able to do your usual activities. You can take care of yourself by trying to:
●Take breaks from the news
●Get regular exercise and eat healthy foods
●Find activities that you enjoy and can do at home
●Stay in touch with your friends and family members
It might help to remember that by doing things like getting vaccinated and following local guidelines, you are helping to protect other people in your community.

Where can I go to learn more?

As we learn more about this virus, expert recommendations will continue to change. Check with your doctor or public health official to get the most updated information about how to protect yourself and others.
For information about COVID-19 in your area, you can call your local public health office. In the United States, this usually means your city or town’s Board of Health. Many states also have a “hotline” phone number you can call.
You can find more information about COVID-19 at the following websites:
●United States Centers for Disease Control and Prevention (CDC):
●World Health Organization (WHO):

Adopted and Modified from Up-To-Date 12/3/21

Eosinophilic Esophagitis

Eosinophilic Esophagitis

Patient education: Eosinophilic esophagitis
What is eosinophilic esophagitis
Eosinophilic esophagitis is a condition that affects the esophagus, the tube that carries food from the mouth to the stomach. This condition is called “EoE” for short. In EoE, the esophagus has cells called “eosinophils” in it. Eosinophils are allergy cells that are not normally found in the esophagus.
Doctors don’t know for sure what causes EoE. But they think it might be caused by allergies, especially food allergies.
EoE sometimes runs in families. It can happen in both children and adults.
What are the symptoms of eosinophilic esophagitis?
Symptoms can be different, depending on a person’s age.
Adults and teens usually have symptoms such as:
●Trouble swallowing – This is the most common symptom. People usually have trouble swallowing solid foods. Some people have pain with swallowing or feel like the food gets stuck in their throat or chest.
●Chest or upper belly pain
●Burning in the chest (heartburn) that doesn’t get better after taking medicine to treat heartburn
Children usually have symptoms such as:
●Feeding problems, such as refusing to eat solid foods
●Nausea or vomiting
●Belly pain
Is there a test for eosinophilic esophagitis?
The test done most often to check for this condition is an upper endoscopy.
During an upper endoscopy, a doctor (called a gastroenterologist) puts a thin tube with a camera and light on the end into your mouth and down into your esophagus. They will look at the lining of the esophagus and take small samples of it. Another doctor will then look at the cells under a microscope to see if you have EoE.
How is eosinophilic esophagitis treated?
Treatment usually involves diet changes and medicines:
●Diet changes – Your doctor might have you avoid foods that could be causing your symptoms. There are 3 main ways to do this. You can:
•Avoid the foods that most commonly cause EoE
•Avoid the foods you are allergic to – To figure out the foods you are allergic to, you might need to see an allergist (allergy doctor) and have tests.
•Go on a special liquid diet and avoid all solid foods
To make sure you get the nutrition you need, your doctor might recommend that you work with a dietitian (food expert). After your symptoms improve, you will be able to add foods back into your diet.
●Medicines – Doctors can use different medicines to treat EoE. One is called a “proton pump inhibitor.” This medicine is usually used to treat acid reflux, which is when acid that is normally in the stomach backs up into the esophagus. People with EoE sometimes have acid reflux, but this medicine can treat EoE, too.
Other medicines include steroids, which help reduce inflammation. (These are not the same as the steroids some athletes take illegally.) Steroids usually come in a device called an inhaler, but you don’t breathe in the steroids the way you normally would with inhaler medicines. Instead, you allow the medicine to build up in your mouth and then you swallow it. Steroids might also be given as a liquid or pill.
In some people, EoE leads to a condition called an esophageal stricture, which is a narrowing of the esophagus. The main treatment for an esophageal stricture in people who do not improve with medicines is a procedure to widen the esophagus, called “dilation.” This procedure is done during endoscopy.

COVID-19 FAQ and Answers

COVID-19 FAQ and Answers

  1. How is SARS-CoV-2 (the virus that causes COVID-19) transmitted?

Person-to-person spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is thought to occur mainly via respiratory droplets, resembling the spread of influenza. With droplet transmission, the virus is released in the respiratory secretions when an infected person coughs, sneezes, or talks if it makes direct contact with the mucous membranes. Infection can also occur if a person touches a contaminated surface and then touches his or her eyes, nose, or mouth. Droplets typically do not travel more than six feet (about two meters).

The extent to which SARS-CoV-2 can be transmitted through the airborne route (through particles smaller than droplets that remain in the air over time and distance) under natural conditions and how much this mode of transmission has contributed to the pandemic are controversial.

While SARS-CoV-2 RNA has been detected in non-respiratory specimens (e.g., stool, blood), neither fecal-oral nor blood borne transmission appear to be significant sources of infection. SARS-CoV-2 infection has been described in animals, but there is no evidence to suggest that animals are a major source of transmission.

2. What is the incubation period for COVID-19?

The incubation period for COVID-19 is thought to be within 14 days following exposure, with most cases occurring approximately four to five days after exposure.

3. What are some of the important SARS-CoV-2 variants?

Multiple SARS-CoV-2 variants are circulating globally. Some variants contain mutations in the surface spike protein, which mediates viral attachment to human cells and is a target for natural and vaccine-induced immunity. Thus, these variants have the potential to be more transmissible, cause more severe disease, and/or evade natural or vaccine-induced immune responses. Although more prevalent in the locations where they were first identified, these variants have subsequently been detected in many other countries, including in the United States:

UK variant was first identified in the United Kingdom in late 2020. This variant is estimated to be more transmissible than wild-type virus. Preliminary data also suggest this variant may cause more severe illness.

South Africa variant was identified in late 2020 in South Africa, where it quickly became the dominant circulating strain. This variant is also believed to be more transmissible than wild-type virus, and there is concern that it evades immune responses; there is no evidence to suggest it impacts disease severity.

Brazil variant was first identified in Japan in travelers from Brazil in late 2020, and subsequently widely detected in specimens from the Amazonas state of Brazil. The variant harbors several mutations, which have the potential to increase transmissibility and impact immunity.

What are the clinical presentation and natural history of COVID-19? The spectrum of illness associated with COVID-19 is wide, ranging from asymptomatic infection to life-threatening respiratory failure. When symptoms are present, they typically arise approximately four to five days after exposure. Symptoms are mild in approximately 80 percent of cases and often include fever, fatigue, and dry cough. Smell and taste disorders have also been reported in patients with COVID-19; whether these symptoms are distinguishing features is unknown. Gastrointestinal symptoms are not frequently reported but may be the presenting feature in some patients. Headache, rhinorrhea, and sore throat are less common.

Dyspnea (shortness of breath that starts suddenly) affects approximately 20 to 30 percent of patients, typically arising five to eight days after symptom onset. Progression from dyspnea to acute respiratory distress syndrome (ARDS) can be rapid; thus, the onset of dyspnea is generally an indication for hospital evaluation and management.

Pneumonia is the most common manifestation of severe disease. ARDS develops in a sizable minority of symptomatic patients and can be associated with a cytokine release syndrome, which is characterized by fever, progressive hypoxia and/or hypotension, and markedly elevated inflammatory markers. ARDS is the leading cause of death, followed by sepsis, cardiac complications, and secondary infections.

The overall case fatality rate is estimated to be between 2 and 3 percent, although it varies widely by age and the true rate is unknown. While severe and fatal illness can occur in anyone, the risk rises dramatically with age and the presence of chronic illnesses, including cardiovascular disease, pulmonary disease, diabetes mellitus, kidney disease, and cancer. For those who recover, illness is often prolonged, lasting approximately two weeks in those with mild disease and three to six weeks in those with severe disease.

5. What factors are associated with severe COVID-19?

Severe illness can occur in otherwise healthy individuals of any age, but it predominantly occurs in adults with advanced age or underlying medical comorbidities. Major comorbidities associated with severe illness and mortality include:

  • Cardiovascular disease
  • Diabetes mellitus
  • Hypertension
  • Chronic lung disease
  • Cancer
  • Chronic kidney disease
  • Obesity (body mass index ≥30)
  • Smoking

6. What are the major cardiac complications in patients with COVID-19? And how often do they occur?

Cardiac manifestations are common in hospitalized patients and occur most frequently in critically ill patients. The most common complications are listed here:

Cardiac troponin elevation, which is a biomarker of myocardial injury, occurs in approximately 10 to 30 percent of hospitalized patients. In the majority of these patients, cardiac signs and symptoms are not present and the cause of the troponin rise is not acute myocardial infarction (MI). However, patients with a clinical presentation (including history or electrocardiogram) suggestive of acute MI require prompt evaluation and treatment.

Usually, troponin elevation in COVID-19 patients is due to other causes of myocardial injury including stress cardiomyopathy, hypoxic injury, myocarditis, right heart strain, microvascular dysfunction, and systemic inflammatory response syndrome. For those without suspected acute MI, further evaluation is focused on testing expected to impact management.

The following complications may occur with or without troponin elevation:

  • Arrhythmias have been reported in approximately 5 to 20 percent of hospitalized cases, and most are asymptomatic. Causes may include hypoxia, electrolyte abnormalities, myocardial injury, and drug effects (such as QT-prolonging agents).
  • Heart failure is the most common symptomatic cardiac complication. Data on its incidence are limited; however, its presence is associated with increased mortality. Heart failure in patients with COVID-19 may be precipitated by acute illness in patients with pre-existing known or undiagnosed heart disease (e.g., coronary artery disease or hypertensive heart disease) or incident acute myocardial injury (e.g., stress cardiomyopathy or acute MI).

7. What are the major thrombotic complications in patients with COVID-19?

COVID-19 is a hypercoagulable state associated with an increased risk of venous thromboembolism (VTE; including deep vein thrombosis and pulmonary embolism) and arterial thrombosis, including stroke, myocardial infarction, and possibly limb ischemia. The risk is highest in individuals in the intensive care unit (ICU), often despite prophylactic anticoagulation. Bleeding is not common but has been seen, especially in the setting of trauma and/or anticoagulation.

8. What are the most common dermatologic syndromes associated with COVID-19?

The most common cutaneous findings reported in patients with COVID-19 include an exanthematous (morbilliform) rash, pernio-like acral lesions, livedo-like lesions, retiform purpura, necrotic vascular lesions, urticaria, vesicular (varicella-like) eruptions, and erythema multiforme-like lesions. An erythematous, polymorphic rash has also been associated with a related multisystem inflammatory syndrome in children. The frequency of cutaneous findings is estimated to range from less than 1 percent to 20 percent of patients with COVID-19.

Uncertainty remains about the strength and mechanisms of associations between reported skin findings and COVID-19. The timing of the appearance of cutaneous findings in relation to the course of COVID-19 has varied, with reports describing skin changes occurring prior to, concomitantly, or following symptoms of COVID-19.

9. What is multisystem inflammatory syndrome associated with COVID-19?

Multisystem inflammatory syndrome in children (MIS-C) is a rare but serious condition that has been reported in patients with current or recent COVID-19 infection or exposure. It shares clinical features with Kawasaki disease (KD), KD shock, and toxic shock syndrome. Clinical features include persistent fever, severe illness with involvement of multiple organ systems, and elevated inflammatory markers. Most children with MIS-C have survived, although some have required intensive care. Pending additional information, children with clinical features of MIS-C should be promptly referred to a specialist in pediatric infectious diseases, rheumatology, cardiology, and/or critical care, as necessary. 

Persistent physical symptoms following acute COVID-19 are common and typically include fatigue, dyspnea, chest pain, and cough. Headache, joint pain, insomnia, anxiety, cognitive dysfunction, myalgias, and diarrhea have also been reported. The time to symptom resolution depends primarily on premorbid risk factors, the severity of the acute illness, and the spectrum of initial symptoms. However, prolonged symptoms are common even in patients with less severe disease who were never hospitalized.

11. Is there a way to distinguish COVID-19 clinically from other respiratory illnesses, particularly influenza?

No, the clinical features of COVID-19 overlap substantially with influenza and other respiratory viral illnesses. There is no way to distinguish among them without testing.

12. When should patients with confirmed or suspected COVID-19 be advised to stay at home? Have an in-person clinical evaluation?

Home management is appropriate for most patients with mild symptoms (eg, fever, cough, and/or myalgias without dyspnea), provided they can be adequately isolated, monitored, and supported in the outpatient setting. However, there should be a low threshold to clinically evaluate patients who have any risk factors for more severe illness, even if they have only mild symptoms. As an example, some outpatients with mild to moderate symptoms, but who have certain risk factors for severe disease, may be candidates for treatment with monoclonal antibody therapy.

Patients being managed at home should be educated about the potential for worsening disease and advised to closely monitor for symptoms of more serious disease, including dyspnea or persistent chest pain. The development of these symptoms should prompt clinical evaluation and possible hospitalization.

13. What laboratory abnormalities are commonly seen in patients with COVID-19?

Common laboratory abnormalities among hospitalized patients with COVID-19 include:

  • Lymphopenia (reported in up to 90 percent)
  • Elevated amino transaminase levels
  • Elevated lactate dehydrogenase levels
  • Elevated inflammatory markers (eg, ferritin, C-reactive protein, and erythrocyte sedimentation rate)

Abnormalities in coagulation testing, elevated procalcitonin levels, and elevated troponin levels have also been reported. The degree of these abnormalities tends to correlate with disease severity.

14. What are the major coagulation abnormalities in patients with COVID-19?

A number of laboratory abnormalities have been reported, including high fibrinogen and D-dimer and mild prolongation of the prothrombin time (PT) and activated partial thromboplastin time (APTT). Abnormal coagulation studies are mainly used to monitor clinical status and to help determine level of care. Very high D-dimer is associated with a high mortality rate. Atypical findings (e.g., severe thrombocytopenia) should be further evaluated.

15. What are the different types of tests for COVID-19?

  • Nucleic acid amplifications tests (NAATs; eg, reverse transcription polymerase chain reaction [RT-PCR]) – RT-PCR for SARS-CoV-2 is the primary test used to diagnose active COVID-19. The test is performed primarily on upper respiratory specimens (including nasopharyngeal swabs, nasal swabs, and saliva) but can also be performed on lower respiratory tract samples. Sensitivity and specificity are generally high, although performance varies based on the specific assay used, specimen quality, and duration of illness.
  • Serology – Serologic tests measure antibodies to SARS-CoV-2 and are primarily used to identify patients who have had COVID-19 in the past as well as patients with current infection who have had symptoms for three to four weeks. Sensitivity and specificity are highly variable, and cross-reactivity with other coronaviruses has been reported.
  • Antigen tests – Antigen tests can also be used to diagnosis active infection, although they are less sensitive than NAATs. These tests are typically performed on nasopharyngeal or nasal swabs.

Both NAATs and antigen tests can be used to screen patients in congregate settings, such as long-term care facilities.

16. How accurate is RT-PCR for SARS-CoV-2? Should two tests be performed or one?

A positive RT-PCR for SARS-CoV-2 generally confirms the diagnosis of COVID-19. However, false-negative tests from upper respiratory specimens have been well documented. If initial testing is negative, but the suspicion for COVID-19 remains, and determining the presence of infection is important for management or infection control, we suggest repeating the test. For hospitalized patients with evidence of lower respiratory tract involvement, the repeat test can be performed on expectorated sputum or a tracheal aspirate, if available.

In many cases, because of the limited availability of testing and concern for false-negative results, the diagnosis of COVID-19 is made presumptively based on a compatible clinical presentation in the setting of an exposure risk (residence in or travel to an area with widespread community transmission or known contact).

17. What are the indications for testing asymptomatic individuals?

Indications for testing asymptomatic individuals include close contact with an individual with COVID-19, screening in congregate settings (eg, long-term care facilities, correctional and detention facilities, homeless shelters), and screening hospitalized patients in high-prevalence regions. Screening may also be indicated prior to time-sensitive surgical procedures or aerosol-generating procedures and prior to receiving immunosuppression.

18. When is the best time to test for COVID-19 following an exposure?

The optimal time to test for COVID-19 following exposure is uncertain. The United States Centers for Disease Control and Prevention (CDC) recommends testing immediately after the exposure is identified to quickly identify infection and, if the test is negative, retesting five to seven days after the last exposure. In some cases, testing can be used to help determine the length of quarantine (eg, reduce the quarantine period to seven days if an individual remains asymptomatic and has a negative viral test within 48 hours of the planned end of quarantine).

19. Can SARS-CoV-2 variants be reliably detected by available diagnostic assays?

Thus far, yes. Most circulating SARS-CoV-2 variants have mutations in the viral spike protein.

While many nucleic acid amplification tests target the gene that encodes the spike protein, they also target other genes. Thus, if a mutation alters one gene target, the other gene targets still function and the test will detect the virus.

Most antigen tests target nucleocapsid protein, so mutations in the spike protein would not impact the accuracy of such antigen tests. 

20. Are there any COVID-19-specific therapies available for non-hospitalized patients?

Antibody-based treatments may reduce the risk of severe disease in high-risk outpatients. However, they require intravenous administration, necessitate the use of valuable ancillary services, and must be given early in the course of illness. These factors make administration operationally complicated.

Monoclonal antibody therapy – In the United States, two combination monoclonal antibody therapies targeting SARS-CoV-2 (bamlanivimab-etesevimab and casirivimab-imdevimab) are available for the treatment of non-hospitalized adults (≥18 years) with mild to moderate COVID-19 and any of the following risk factors for severe disease:

  • Body mass index (BMI) ≥35 kg/m2
  • Chronic kidney disease
  • Diabetes mellitus
  • Immunosuppression (immunosuppressive disease or treatment)
  • ≥65 years of age
  • ≥55 years of age and who have cardiovascular disease, and/or hypertension, and/or chronic obstructive pulmonary disease (or other chronic respiratory disease)

Given the limited data and intensive resources needed for administration, experts suggest not routinely treating patients with monoclonal antibodies. Nevertheless, if supporting infrastructure is in place, it is reasonable to offer bamlanivimab-etesevimab, which is recommended by the National Institutes of Health based on preliminary evidence of a mortality reduction.

SARS-CoV-2 variants may impact the clinical efficacy of monoclonal antibody therapies. In the United States, due to the increasing prevalence of variants that are resistant to bamlanivimab, this agent is no longer available as for use as monotherapy and should only be administered in combination with etesevimab. Clinicians should be aware of the prevalence of variants in their local area and the potential resistance to available monoclonal antibody therapies.

If monoclonal antibody therapy is used, it should be given as soon as possible after illness onset and positive SARS-CoV-2 test has been obtained; ideally within three days, but no longer than 10 days after symptom onset.

High-titer convalescent plasma – Limited high-quality data suggest that early administration of high-titer convalescent plasma may lower the risk of progression to severe disease in high-risk older adults (age ≥75 years or ≥65 years with specific comorbidities) with mild illness. Convalescent plasma appears to have the greatest efficacy when given within 72 hours of symptom onset.

As with monoclonal antibody therapy, high-titer convalescent plasma therapy remains investigational and should be administered through a clinical trial if available. Experts do not routinely treat COVID-19 in non-hospitalized patients with glucocorticoids, antibiotics, anticoagulation, or antiplatelet therapy. 

21. What advice should be given to patients with known or presumed COVID-19 managed at home?

For most patients with COVID-19 who are managed at home, we advise the following:

  • Supportive care with antipyretics/analgesics (e.g., acetaminophen) and hydration
  • Close contact with their health care provider
  • Monitoring for clinical worsening, particularly the development of new or worsening dyspnea, which should prompt clinical evaluation and possible hospitalization
  • Separation from other household members, including pets (eg, staying in a separate room when possible and wearing a mask when in the same room)
  • Frequent hand washing for all family members
  • Frequent disinfection of commonly touched surfaces.

22. How long patients should be cared for at home stay isolated?

For most symptomatic immunocompetent patients cared for at home, isolation can usually be discontinued when the following criteria are met:

  • At least 10 days have passed since symptoms first appeared AND
  • At least one day (24 hours) has passed since resolution of fever without the use of fever-reducing medications AND 
  • There is improvement in symptoms (e.g., cough, shortness of breath)

In some cases, patients may have had laboratory-confirmed COVID-19 but did not have any symptoms when they were tested. In such patients, home isolation can usually be discontinued using a time-based strategy (when at least 10 days have passed since the date of their first positive COVID-19 test) as long as there was no evidence of subsequent illness.

For those who had severe disease or are severely immunocompromised, the duration of isolation may need to be extended and/or testing may be needed to confirm resolution.

23. What is the significance of a persistently positive RT-PCR for weeks after illness?

Patients diagnosed with COVID-19 can have detectable SARS-CoV-2 RNA in upper respiratory tract specimens for weeks after the onset of symptoms. However, prolonged viral RNA detection does not necessarily indicate prolonged infectiousness. According to the CDC, isolation of infectious virus more than 10 days after illness onset is rare in patients whose symptoms have resolved.

There is no standardized approach to management of patients with persistently positive reverse transcription polymerase chain reaction (RT-PCR) 10 days or more after resolution of symptoms. However, such patients are generally felt to have low infectiousness, particularly after mild to moderate disease and in the absence of immunocompromised. This is why symptom- and time-based approaches for discontinuation of precautions are recommended for most patients.

24. Should I use acetaminophen or NSAIDs when providing supportive care?

Nonsteroidal anti-inflammatory drugs (NSAIDs) have been theorized to cause harm in patients with COVID-19, but clinical data are limited. Given the uncertainty, we use acetaminophen as the preferred antipyretic agent for most patients rather than NSAIDs. If NSAIDs are needed, we use the lowest effective dose. We do not routinely discontinue NSAIDs in patients using them for the management of chronic illnesses.

The US Food and Drug Administration (FDA), the European Medicines Agency (EMA), and the World Health Organization (WHO) do not recommend that NSAIDs be avoided when clinically indicated. 

25. Do ACE inhibitors and ARBs increase the likelihood of severe COVID-19?

Patients receiving angiotensin-converting-enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) should continue treatment with these agents. The membrane-bound ACE2 functions as a receptor for SARS-CoV-2, and because ACE inhibitors and ARBs may increase the expression of ACE2, there is speculation that patients with COVID-19 who are receiving these agents may be at increased risk for severe disease. However, there is no evidence to support an association of ACE inhibitors and ARBs with more severe disease, and it is also possible that these drugs may attenuate the severity of disease. In addition, stopping these agents in some patients can exacerbate comorbid cardiovascular or kidney disease and increase mortality. 

26. Should patients using inhaled glucocorticoids for asthma or COPD be advised to stop these medications to prevent COVID-19?

No, patients with asthma or chronic obstructive pulmonary disease (COPD) who need inhaled glucocorticoids to maintain control of their asthma or COPD should continue them at their usual dose. When indicated, inhaled steroids help to minimize risk of an asthma or COPD exacerbation and the associated need for interaction with the health care system. There is no good evidence that inhaled glucocorticoids increase susceptibility to COVID-19 or have an adverse effect on the course of infection. Stopping them may worsen asthma or COPD control and thereby increase the risk for complications of COVID-19, if acquired.

27. Should patients with COVID-19 and an acute exacerbation of asthma or COPD be treated with systemic glucocorticoids?

Yes, patients with COVID-19 infection and a concomitant acute exacerbation of asthma or COPD should receive prompt treatment with systemic glucocorticoids as indicated by usual guidelines. Delaying therapy can increase the risk of a life-threatening exacerbation. While the World Health Organization (WHO) and United States Centers for Disease Control and Prevention (CDC) recommend glucocorticoids not be routinely used in the treatment of COVID-19 infection, exacerbations of asthma and COPD are considered appropriate indications for use. Overall, the known benefits of systemic glucocorticoids for exacerbations of asthma and COPD outweigh the potential harm in COVID-19 infection. 

28. Have any medications been shown to prevent COVID-19?

No agent is known to be effective for preventing COVID-19. While hydroxychloroquine is being studied as a prophylactic agent, randomized trials found that it was not effective for prevention. We recommend that neither this medication nor any other be used for prophylaxis outside of clinical trials.

29. What PPE is recommended for health care workers taking care of patients with suspected or confirmed COVID-19?

Any personnel entering the room of a patient with suspected or confirmed COVID-19, regardless of COVID-19 vaccination status, should wear the appropriate personal protective equipment (PPE): gown, gloves, eye protection (full face shield preferred rather than goggles or a surgical mask with an attached eye shield), and a respirator (eg, an N95 respirator). If the supply of respirators is limited, medical masks are an acceptable alternative, except during aerosol-generating procedures (e.g., tracheal intubation and extubating, tracheotomy, bronchoscopy, noninvasive ventilation, cardiopulmonary resuscitation).

30. Should patients be advised to wear masks in public?

Yes, patients should be advised to wear masks when in public spaces (indoors or outdoors) or when around individuals outside of their household. This is consistent with recommendations from the World Health Organization (WHO) and the United States Centers for Disease Control and Prevention (CDC). The CDC also advises that individuals who have been fully vaccinated should still wear masks in public but can forgo mask use when visiting with other vaccinated individuals or with unvaccinated members of a single household who are at low risk for severe COVID-19.

The rationale for individuals (regardless of symptoms) to wear a mask in the community is to contain secretions of and prevent transmission from individuals with infection, including those who have asymptomatic or pre symptomatic infection. Masks also reduce exposure to SARS-CoV-2 for the wearer. 

31. Does protective immunity develop after SARS-CoV-2 infection? Can reinfection occur?

SARS-CoV-2-specific antibodies and cell-mediated responses are induced following infection. Evidence suggests that some of these responses are protective and generally last at least several months. However, it is unknown whether all infected patients mount a protective immune response and how long protective effects last beyond the first few months after infection.

The short-term risk of reinfection (e.g., within the first few months after initial infection) appears low. However, sporadic cases of reinfection have been documented.

32. Which vaccines are currently available in the United States? Worldwide?

In the United States, three vaccines are available:

  • BNT162b2 (Pfizer-BioNTech COVID-19 vaccine)
  • mRNA-1273 (Moderna COVID-19 vaccine)
  • Ad26.COV2.S (Janssen COVID-19 vaccine)

BNT162b2 and mRNA-1273 are mRNA vaccines are delivered in lipid nanoparticles. Once injected and taken up into muscle cells, the mRNA expresses the SARS-CoV-2 surface spike protein. Spike protein mediates viral attachment to human cells. Expression of the spike protein induces binding and neutralizing antibody responses.

Ad26.COV2.S (Janssen) has been approved for use in the United States. This vaccine is based on a replication-incompetent adenovirus 26 vector that expresses a stabilized spike protein. This is a single shot vaccine.

Outside of the United States, vaccine availability varies regionally. One of the most widely available vaccines is ChAdOx1 nCoV-19/AZD1222 (University of Oxford, AstraZeneca, and the Serum Institute of India vaccines), an adenovirus vector-based DNA vaccine that also expresses the surface spike protein. 

Numerous additional vaccine candidates are being evaluated for prevention of COVID-19, including nucleic acid-based (mRNA and DNA) vaccines, viral-vector vaccines, and inactivated or recombinant protein vaccines.

33. How efficacious is vaccination at preventing symptomatic COVID-19?

BNT162b2 (Pfizer-BioNTech COVID-19 vaccine) had 95 percent efficacy in preventing symptomatic COVID-19 at or after day 7 following completion of a two-dose series.

MRNA-1273 (Moderna COVID-19 vaccine) had 95 percent efficacy in preventing symptomatic COVID-19 at or after day 7 following completion of a two-dose series. 

Ad26.COV2.S (Janssen) had 66 percent efficacy against moderate to severe COVID-19 and 85 percent efficacy against severe COVID-19 at or after 28 days following administration of a single dose. 

ChAdOx1 nCoV-19/AZD1222 (AstraZeneca COVID-19 vaccine) had 70 percent efficacy in preventing symptomatic COVID-19 at or after two weeks following completion of a two-dose series. 

34. How effective is vaccination against SARS-CoV-2 variants?

Many circulating SARS-CoV-2 variants contain mutations in the surface spike protein, which is the most common vaccine target. The impact of these mutations on vaccine efficacy is not well studied and undoubtedly varies by variant and by vaccine type.

Preliminary evidence suggests that both BNT162b2 (Pfizer-BioNTech COVID-19 vaccine) and mRNA-1273 (Moderna COVID-19 vaccine) retain neutralizing activity against B.1.1.7, the dominant viral variant in the United Kingdom and other countries. Both vaccines have reduced neutralizing activity against B.1.351, the dominant variant in South Africa, though the clinical significance of this reduction is not known.

The efficacy of Ad26.COV2.S (Janssen) varied by region: 74 percent in the United States, 66 percent in Brazil, where the P.2 variant was prevalent, and 52 percent in South Africa, where most infections were caused by the variant B.1.351. Nevertheless, vaccine efficacy against severe/critical disease was similar across regions.

The efficacy of ChAdOx1 nCoV-19/AZD1222 (AstraZeneca COVID-19 vaccine) against B.1.1.7 appears to be similar to wild-type virus despite reduced neutralizing activity.

As mutations continue to accumulate, there is potential for vaccine efficacy to further decline. 

35. What are the indications and contraindications to vaccination?

For patients in the United States, experts recommend vaccination with either BNT162b2 (Pfizer-BioNTech COVID-19 vaccine), mRNA-1273 (Moderna COVID-19 vaccine), or Ad26.COV2.S (Janssen COVID-19 vaccine).

  • Individuals ≥16 years old are eligible for BNT162b2.
  • Individuals ≥18 years old are eligible for mRNA-1273 and Ad26.COV2.S.

Contraindications to these vaccines are:

For the mRNA COVID-19 vaccines:

  • A history of a severe allergic reaction, such as anaphylaxis, after a previous dose of an mRNA COVID-19 vaccine or to any of its components (including polyethylene glycol).
  • An immediate allergic reaction of any severity (including hives) to a previous dose of an mRNA COVID-19 vaccine, to any of its components, or to polysorbate (with which there can be cross-reactive hypersensitivity to polyethylene glycol). Such individuals should not receive an mRNA COVID-19 vaccine unless they have been evaluated by an allergy expert who determines that it can be given safely.

The United States Advisory Committee on Immunization Practices lists history of severe allergic reaction to any other vaccine or injectable therapy (that does not share the same components as the mRNA COVID-19 vaccines) as a precaution, but not contraindication, to mRNA COVID-19 vaccination.

For Ad26.COV2.S – A history of a severe allergic reaction, such as anaphylaxis, to any of its components.

Individuals with a precaution to vaccination, as well as any individual with a history of anaphylaxis that does not result in a contraindication to vaccination, should be monitored for 30 minutes after vaccination. All other recipients should be monitored for 15 minutes.

36. What adverse effects are associated with vaccination?

The more common adverse effects for all vaccine types include local injection site reactions, fever, headache, fatigue, chills, myalgias, and arthralgia. These reactions are more common in younger individuals and after the second dose.

Anaphylaxis is a rare adverse event reported following receipt of mRNA vaccines. In the United States, 21 episodes of anaphylaxis were reported to the CDC after 1,893,360 doses had been administered (11.1 events per one million doses). Anaphylaxis is more common in individuals with a history of allergies.

37. Is there an increased risk of thromboembolism associated with the ChAdOx1 nCoV-19/AZD1222 (AstraZeneca) vaccine? Should this vaccine be avoided?

In March 2021, rare thromboembolic events following vaccination with ChAdOx1 nCoV-19/AZD1222 were investigated by the European Medicines Agency (EMA). The EMA found that the overall rate of thromboembolic disorders was lower than expected for the general population, but that two specific types of events, blood clots in multiple vessels (suggestive of disseminated intravascular coagulation [DIC]) and cerebral venous sinus thrombosis (CVST), occurred more frequently than expected. The EMA concluded that the benefit of ChAdOx1 nCoV-19/AZD1222 outweighs the extremely small possibility of DIC or CVST; vaccine recipients should be aware of the possible association and seek immediate care for symptoms suggestive of thrombocytopenia and/or thrombotic complications. 

38. Can analgesics or antipyretics be taken for side effects following vaccination?

Analgesics or antipyretics (e.g., nonsteroidal anti-inflammatory drugs [NSAIDs] or acetaminophen) can be taken for local or systemic side effects following vaccination. However, pre-emptive use of these agents prior to vaccination is not recommended because of the uncertain impact on immune response to the vaccine. 

39. Can other vaccines be given with COVID-19 vaccine?

No, other vaccines should generally not be administered within 14 days of COVID-19 vaccine administration because there are no data regarding the safety and efficacy of co administration. However, when the benefits of vaccination are deemed to outweigh the uncertain risk of co administration (e.g., tetanus toxoid-containing vaccination as part of wound management, measles vaccination in an outbreak, repeat mRNA COVID-19 vaccination when availability is limited), vaccination within a shorter time frame is reasonable. 

40. What if the second dose of an mRNA vaccine cannot be given because of a prior reaction?

For individuals who received a first dose of an mRNA vaccine but cannot receive either mRNA vaccine for the second dose (e.g., because of contraindications), Ad26.COV2.S can be given as long as there is not also a contraindication to Ad26.COV2.S.

The CDC suggests giving Ad26.COV2.S at least 28 days after the mRNA vaccine dose. Such individuals should be considered to have received a complete AD26.COV2.S vaccine regimen. 

41. Should people who have had SARS-CoV-2 infection be vaccinated? If so, when? What if a patient acquires COVID-19 after the first dose?

Yes, individuals with a history of SARS-CoV-2 infection should be vaccinated. Vaccination can be given as soon as the individual has recovered from acute infection (if symptomatic) and meets criteria for discontinuation of isolation precautions. Pre-vaccination serologic screening is not recommended. If infection is diagnosed after receipt of the first vaccine of a two-dose series (e.g., with the mRNA COVID-19 vaccines), the second dose should still be given.

Delaying vaccination for 90 days from the time of infection is also reasonable; the risk of reinfection during this time period is low, and delaying vaccination allows other people to receive the vaccination sooner. Delaying vaccination for 90 days is also suggested for individuals who were treated with monoclonal antibodies or convalescent plasma.

42. What should I tell patients about donating blood or plasma during the pandemic?

Blood donation is particularly important during the pandemic due to concerns that the supply could become critically low. Having a history of COVID-19 is not an exclusion to donation as long as the illness resolved at least 14 days prior to donation.

Vaccination for COVID-19 is also not a contraindication to blood donation. Individuals who have received an mRNA vaccine or other non-infectious vaccine (nonreplicating, inactivated) can donate immediately; those who have received a live-attenuated viral vaccine (and those who are unsure which vaccine they received) should refrain from donating blood for a short waiting period (e.g., 14 days) after receiving the vaccine.

Persons who have recovered from COVID-19 are encouraged to donate plasma, because convalescent plasma is an investigational treatment for COVID-19. COVID-19 vaccine recipients are not eligible for convalescent plasma donation. 

I did not collect information on care of Hospitalized patients since that is not needed for this posting.

Compiled from Various sources mostly from Up-to-date and posted in public interest.

Tarun Kothari MD, FACG, FACP


What is Liver Cancer?

What is Liver Cancer?

Patient Education: Hepatocellular Carcinoma (Liver Cancer):

What is liver cancer?

Liver cancer happens when normal cells in the liver change into abnormal cells and grow out of control. The liver is a big organ in the upper right side of the belly.

Most people who get liver cancer have long-term liver disease (also called chronic liver disease). Having long-term liver disease increases a person’s chances of getting liver cancer. The most common and most serious form of long-term liver disease is a condition called “cirrhosis,” which scars the liver.

What are the symptoms of liver cancer?

Liver cancer does not usually cause any symptoms of its own. A few patients might have a lump or mild pain in the upper belly, feel full early on when they try to eat, or lose weight.

Others might have symptoms that are caused by the liver disease they had before they got cancer. Those symptoms can get worse or come back because of the cancer. They include:

  • Swelling of the belly or legs
  • The skin or white part of the eyes turning yellow

If you have these symptoms, tell your doctor or nurse.

Is there a test for liver cancer?

Yes. If your doctor suspects you have liver cancer, they will do 1 or more of the following tests:

  • Blood tests
  • Imaging tests: An MRI scan, CT scan, ultrasound, or other imaging test. Imaging tests create pictures of the inside of the body and can show abnormal growths.
  • Biopsy – For this test, a doctor will remove a small sample of tissue from the liver. Another doctor will look at the sample under a microscope to see if it has cancer.

What is liver cancer staging?:

Cancer staging is a way in which doctors find out if a cancer has spread past the layer of tissue where it began and, if so, how far.

How is liver cancer treated?

Liver cancer can be treated in different ways. Treatment depends on the stage of your cancer. It also depends on how healthy your liver is (in other words, how serious your liver disease was before you got cancer). The different treatments include:

  • Surgery – Liver cancer can sometimes be treated with surgery to remove the part of the liver with the cancer.
  • Liver transplant – A liver transplant is a type of surgery in which a doctor replaces a diseased liver with a healthy liver from another person.
  • Ablation therapy – Ablation therapy is a procedure that can kill cancer cells in the liver. It does not involve surgery. Doctors can do ablation therapy in different ways. They can kill the cancer cells using heat, microwaves, a laser, or radiation therapy.
  • Blocking the cancer’s blood supply – Doctors can do a procedure called “embolization” to block off the blood vessel that sends blood to the cancer. This keeps the cancer from growing by “starving” it of its blood supply. Sometimes, the embolization procedure is combined with chemotherapy (“chemoembolization”) or radiation (“radioembolization”).
  • Immunotherapy – This is the term doctors use for medicines that work with the body’s infection-fighting system (the “immune system”) to stop cancer growth.
  • Chemotherapy – Chemotherapy is the medical term for medicines that kill cancer cells or stop them from growing.

What happens after treatment?

After treatment, you will be checked every so often to see if the cancer comes back. Regular follow up tests usually include exams, blood tests, and imaging tests.

You should also watch for the symptoms listed above. Having those symptoms could mean the cancer has come back. Tell your doctor or nurse if you have any symptoms.

If you had a liver transplant, you will need to take medicines called “anti-rejection medicines” for the rest of your life. These medicines help keep your body from reacting badly to your new liver.

What happens if the cancer comes back or spreads?

If the cancer comes back or spreads, your doctor will talk with you about possible treatment choices. These might include the treatments listed above.

What else should I do?

It is important to follow all your doctor’s instructions about visits and tests. It’s also important to talk to your doctor about any side effects or problems you have during treatment. People who have liver cancer, especially if they have long-term liver disease, should avoid alcohol and any drugs that could be harmful to the liver.

Getting treated for liver cancer involves making many choices, such as what treatment to have.

Always let your doctors and nurses know how you feel about a treatment. Any time you are offered a treatment, ask:

  • What are the benefits of this treatment? Is it likely to help me live longer? Will it reduce or prevent symptoms?
  • What are the downsides to this treatment?
  • Are there other options besides this treatment?
  • What happens if I do not have this treatment?

Compiled from UpToDate.

What is Cirrhosis of Liver?

What is Cirrhosis of Liver?

Patient education: Cirrhosis

Cirrhosis is a disease that scars the liver. The liver is a big organ in the upper right side of the belly. Damage to the liver can cause heavy bleeding, swelling, and breathing problems.

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What are the symptoms of Cirrhosis?

Some people with cirrhosis have no symptoms. When symptoms do occur, they can include:

  • Swelling in the belly and legs, and fluid buildup in the lungs
  • Heavy bleeding from blood vessels in the esophagus, the tube that connects the mouth to the stomach
  • Bruising or bleeding easily
  • Trouble breathing
  • Feeling full
  • Feeling tired
  • Trouble getting enough sleep or sleeping too much
  • Yellowing of the skin or whites of the eyes, called jaundice
  • Confusion that can come on suddenly
  • Coma

Cirrhosis also makes it more likely that you will get infections, and it can increase your risk of liver cancer.

What causes cirrhosis?

When something harms the liver, the organ tries to fix itself. In the process, scars form. Causes of liver damage include:

  • Heavy alcohol use – People who abuse alcohol or who are addicted to it are most at risk for cirrhosis.
  • Hepatitis B or hepatitis C – Viruses cause these liver diseases. People can catch the viruses by sharing needles or having sex with people who are infected.
  • Nonalcoholic steatohepatitis (NASH) – People with this condition often don’t drink alcohol. Doctors aren’t sure what causes NASH, but many people who have it are overweight and have diabetes.

Is there a test for cirrhosis?
Yes. Tests include:

  • Biopsy – In this test, a doctor puts a needle into your liver and takes out a small sample of tissue. The sample will show how severe the damage is.
  • Blood tests – Results can show what is causing the disease.
  • Imaging – Your doctor might take pictures of your liver with an ultrasound machine or with a MRI.

Is there anything I can do to prevent further liver damage?

Yes. To help protect your liver:

  • Avoid alcohol
  • Talk to your doctor before you start taking any new medicines, including pain killers such as ibuprofen (sample brand names: Advil, Motrin), naproxen (sample brand name: Aleve), or acetaminophen (sample brand name: Tylenol). Also talk to your doctor before taking any herbs, vitamins, or supplements. Some medicines and supplements can damage the liver.
  • Get vaccinated against hepatitis A and B if you have not had the infections before.

How is cirrhosis treated?:

Treatments depend on the cause of cirrhosis, how severe it is, and what symptoms you have. Treatments fall into a few main categories, including those that:

  • Treat the cause of the disease – Some causes of cirrhosis can be treated. For example, people with cirrhosis caused by alcohol abuse can try to stop drinking. People with chronic hepatitis C or B can take medicines.
  • Lower the risk of bleeding – Cirrhosis can cause the blood vessels around the esophagus to swell or even burst and bleed. To prevent that from happening, doctors can:
  • Prescribe medicines called “beta blockers.” These medicines reduce blood pressure in the liver and help reduce the chance of bleeding.
  • Place tiny bands around the swollen blood vessels (this procedure is called “variceal band ligation”)
  • Decrease fluid buildup in the belly – In people with cirrhosis, the belly sometimes fills with fluid. To decrease fluid buildup, doctors can:
  • Prescribe medicines called “diuretics.” These medicines make you urinate a lot. People who take diuretic medicines often must also reduce the amount of salt they eat.
  • Drain the fluid from your belly using a needle (this procedure is called a “paracentesis”)
  • Implant a device in the liver that reduces fluid buildup in the belly (this procedure is called “TIPS”)
  • Treat or prevent infection – People with cirrhosis have a higher than normal chance of getting infections. When they get an infection, they can also get much sicker than people without cirrhosis. As a result, people with cirrhosis sometimes need antibiotics to either treat or prevent infection. Most people with cirrhosis should also get the flu vaccine and other vaccines to prevent common infections.
  • Treat confusion – Advanced cirrhosis can lead to confusion. Doctors usually use lactulose (a medicine that softens stool) or certain antibiotics to treat the confusion.

Will I need a new liver?

People with severe cirrhosis need a new liver. Talk to your doctor about the surgery before you get too sick, to find out if a liver transplant might be an option for you. People often have to wait for up to 2 years to get a new liver.
Can cirrhosis be prevented?

You can reduce your chances of getting cirrhosis by:

  • Getting help if you have an alcohol problem
  • Getting the vaccines for hepatitis B and hepatitis A, if you haven’t already
  • Using condoms when having sex
  • Not sharing drug needles

Compiled from UpToDate.

Iron Deficiency Anemia

Iron Deficiency Anemia

Patient education: Anemia caused by low iron

What is anemia? Anemia is the term doctors and nurses use when a person has too few red blood cells. Red blood cells are the cells in your blood that carry oxygen. If you have too few red blood cells, your body might not get all the oxygen it needs.

ANEMIA SIGNS AND SYMPTOMS Many people with iron deficiency anemia have no symptoms at all. Of those who do, the most common symptoms include:





●Difficulty exercising (due to shortness of breath, rapid heartbeat)

●Brittle nails

●Sore tongue

●Restless legs syndrome

●Pica (an abnormal craving to eat non-food items, such as clay or dirt, paper products, or cornstarch)

●Pagophagia (an abnormal craving to eat ice)

ANEMIA CAUSES Two common causes of iron deficiency anemia are blood loss (most common) and decreased absorption of iron from food.

Blood loss — The source of blood loss may be obvious, such as in women who have heavy menstrual bleeding or multiple pregnancies, or a person with a known bleeding ulcer. In other cases, the source of the blood loss is not visible, as in someone who has chronic bleeding in their gastrointestinal (GI) tract (stomach, small intestine, colon). This may appear as diarrhea with black, tarry stools, or, if the blood loss is very slow, the stool may appear normal. Donating blood can also cause iron deficiency, especially if it is done on a regular basis.

Decreased iron absorption — Normally, the body absorbs iron from food through the GI tract. If the GI tract is not functioning correctly, as is the case in people with certain conditions such as celiac disease, autoimmune gastritis, other forms of stomach inflammation, gastric bypass surgery (for weight loss), or other forms of weight loss surgery, an inadequate amount of iron may be absorbed, leading to iron deficiency anemia.

Other causes — A common cause of iron deficiency anemia in developing countries is a lack of foods that contain iron. However, this is rarely seen in adults in developed countries such as the United States because many foods contain iron, and others have added iron (breakfast cereal, bread, pasta). Iron is also available in some plant-based foods.

Pregnant and postpartum women may develop iron deficiency anemia because of the increased iron requirements of the growing fetus and placenta and blood loss at the time of delivery.

Is there a test for anemia? Yes, your doctor or nurse can test your blood for anemia. The things they most often check are the “hemoglobin level” and “hematocrit.” These show up on a test called the “complete blood count” or “CBC.”

How is iron deficiency anemia treated? The first step in treatment is to find out whether your anemia is caused by blood loss. If so, your doctor or nurse will want to find out why you are bleeding.

Blood loss can be related to stomach ulcers, bowel problems, or other issues. In women, blood loss can be related to heavy periods.

Whatever the cause of your anemia, your doctor or nurse can treat it by giving you iron. If the anemia is severe, you might need a blood transfusion. You might also need treatment for the cause of the bleeding.

People with iron deficiency anemia need to get iron. Eating foods with iron will not do enough to cure the anemia. You can get extra iron in pills or through a thin tube that goes into a vein, called an “IV.” Most people get it in pills. Your doctor or nurse will tell you how much to take, and for how long.

Iron pills can cause side effects such as upset stomach and constipation (too few bowel movements). If you have side effects, ask your doctor or nurse what to do. They can suggest ways to reduce these side effects or switch you to IV iron.

Adopted from UpToDate