Contraindications to surgery
- –Absolute: Diabetic Coma, DKA
- –Poor nutrition: albumin <3, transferrin <200,weight loss <20%
- –Severe liver failure: bili >2, PT >16, ammonia > 150 or encephalopathy
- –Smoker: stop smoking 8wks prior to surgery
- If a CO2 retainer, go easy on the O2 in the post-op period. Can suppress respiratory drive.
- Tells you who is at greatest risk for surgery
- –#1 = CHF
- Check EF. If <35%, no surgery
- –#2 = MI w/in 6mo
- Check EKG -> stress test -> cardiac cath -> revascularization
- –#3 =arrhythmia
- –#4 =Old (age >70)
- –#5 =Surgery is emergent
- –#6 =Aortic Stenosis, poor medical condition, surg in chest/abd
- Listen for murmur of AS
- Late systolic, crescendo-decrescendo murmur that radiates to carotids.
- ↑ with squatting, ↓ with decrease preload
- Listen for murmur of AS
|Cardiac||Heart Failure, EF < 35%|
MI within 6 mos.
|Stenting + Plavix|
BB, Ace-I, ASA, Statin
Interstitial lung disease (ILD)
|Ventilation issue rather than oxygen||PFTs |
– low O2 = bad
– high CO2 = worse
|Smoking cessation for 8 weeks before surgery|
Quitting closer to surgery is worse
|Liver||Child-Pugh (class A, B, or C)|
MELD = 3.78×ln[serum bilirubin (mg/dL)] + 11.2×ln[INR] + 9.57×ln[serum creatinine (mg/dL)] + 6.43
Contraindication: most surgeries
|Diabetic Ketoacidosis||Diabetic with elevated blood glucose||Check sugar||DONT DO surgery!!! |
IVF + Insulin
– lost 20% of body weight in 3 mos
– albumin < 3
– or failed skin anergy test
|Need adequate nutrition for healing||CRP, prealbumin to ensure low ablumin is from nutrition|
Skin anergy test
|PO > IV|
10 days > 5 days
Preoperative evaluation checklist
- Meds to Stop:
- vit E (2wks)
- Warfarin (5 days) –drop INR to <1.5 (can use vit K)
- Take ½ the morning dose of insulin, if diabetic
- If CKD on dialysis: Dialyze 24 hours pre-op
- Check the BUN and Creatinine:
- –if BUN > 100
- There is an increased risk of post-op bleeding 2/2 uremic platelet dysfunction
- Expect on coagulation panel: Normal platelets but prolonged bleeding time
- –if BUN > 100
- Assist-control -> set TV and rate but if pt takes a breath, vent gives the volume.
- Pressure support (Important for weaning) -> pt rules rate but a boost of pressure is given (8-20).
- CPAP -> pt must breathe on own but + pressure given all the time.
- PEEP (Used in ARDS or CHF) -> pressure given at the end of cycle to keep alveoli open (5-20).
If a patient on a vent
- Best test to evaluate management: ABG
- If PaO2 is low: increase FiO2
- If PaO2 is high: decrease FiO2
- If PaCO2 is low (pH is high): Decrease rate of Tidal Volume
- If PaCO2 is high (pH is low): Increase rate or TV
- Tidal Volume is more efficient to change.
- *Remember minute ventilation equation & dead space*
|During surgery||Family hx|
Bad reaction to anesthesia
|Day 0||Bacteremia (wound)||Blood cx||Ab|
|Day 1||Atelectasis (wind)||Neg CXR||Incentive spirometer||Spirometer|
|Day 2||Pneumonia (wind)||Abx|
Vancomycin + Pip/Tazo for HAP
|Day 3||UTI (water)||Urinalysis |
(leuk esterase +, nitrites +, no epithelial cells)
|Abx||Remove Catheter early|
|Day 5||DVT (walking)||Bilateral Lower Extremity US||Heparin -> Warfarin||Ambulation|
|Day 7||Wound (walking)||Cellulitis is visible|
US (r/o abscess)
|Day 10 – 14||Abscess (wound)||CT scan|
Fever on POD #1
- –Most common cause, low fever (<101) and non-productive cough: Atelectasis
- Dx: CXR-see bilateral lower lobe fluffy infiltrates
- Tx: Mobilization and incentive spirometry.
- –High fever (to 104!!), very ill-appearing: Nec Fasciitis
- Pattern of spread: In subQ along Scarpa’s fascia.
- Common bugs: GABHS or clostridium perfringens
- Tx: IV PCN, Go to OR and debride skin until it bleeds
- –High fever (>104!!) muscle rigidity: Malignant Hyperthermia
- Caused by: Succinate or Halothane
- Genetic defect: Ryanodine receptor gene defect
- Treatment: Dantrolene Na (blocks RYR and decrease intracellular calcium.
Fever on POD #3-5
- –Fever, productive cough, diaphoresis: Pneumonia
- Tx: Check sputum sample for culture, cover w/ moxi etc to cover strep pneumo in the mean time.
- –Fever, dysuria, frequency, urgency, particularly in a patient w/ a foley: UTI
- Next best test: UA (nitritie and LE) and culture.
- Tx: Change foley and treat w/ wide-spec abx until culture returns.
Fever > POD 7
- –Pain & tenderness at IV site: Central line infection
- Tx: Do blood cx from the line. Pull it. Abx to cover staph.
- –Pain @ incision site, edema, induration but no drainage: Cellulitis
- Tx: Do blood cx and start antibiotics
- –Pain @ incision site, induration WITH drainage: Simple Wound Infection
- Tx: Open wound and repack. No abx necessary
- –Pain w/ salmon colored fluid from incision: Dehiscence
- Tx: Surgical emergency! Go to OR, IV abx, primary closure of fascia
- –Unexplained fever: Abdominal Abscess
- Dx: CT w/ oral, IV and rectal contrast to find it. Diagnostic lap.
- Tx: Drain it! Percutaneously, IR-guided, or surgically.
- –Random -> thyrotoxicosis, thrombophlebitis, adrenal insufficiency, lymphangitis, sepsis.
Post Operative Problems
Altered Mental Status
|ARDS||loud and confused||Noncardiogenic PE||CXR – white out||PEEP|
|Delirium Tremens||48-72 hours after admission|
|Alcohol Withdrawal||Tx: Benzodiazepines|
ppx: long acting benzo
|BMP||Na and/or Ca replacement|
|Hypoxia||AMS + Low Sat||Atelectasis |
pain from post-op
- Check pH -> if <7.4 = acidotic.
- Next Check HCO3 and pCO2:
- –If HCO2 is high and pCO2 is high: Respiratory Acidosis
- –If HCO2 is low and pCO2 is low: Metabolic Acidosis
- Next Check anion gap (Na –[Cl+ HCO3]), normal: 8-12
- Gap acidosis = MUDPILES
- Non-gap acidosis = diarrhea, diuretic, RTAs (I< II, IV)
- Check pH if >7.4 = alkalotic.
- Next Check HCO3 and pCO2:
- –If HCO3 is low and pCO2 is low -> Respiratory Alkalosis
- –If HCO3 is high and pCO2 is high -> Metabolic Alkalosis
- Next Check urine [Cl]
- If [Cl] < 20: Vomiting/NG, antacids, diuretics
- If [Cl] > 20: Conn’s, Bartter’s Gittleman’s.
|< 30 = reassurance x 2-3 cycles|
< 30 + persists = US
< 30 + cyst on US = FNA
< 30 + cyst resolves = reassurance
Mammogram & Core needle biopsy if:
> 30 yo
US shows mass
Cyst recurs after aspiration
|Local Disease: Surgical Therapy|
Lumpectomy + radiation or Mastectomy
Sentinel LN biopsy and then
Axillary LN Dissection if +
Spread Disease: Systemic Therapy
Chemo: doxorubicin, paclitaxel
Her 2 Neu+: Trastuzumab
USPTF: start at 50 q 2 years
ACS: start at 40 q 1 year
Breast MRI: BRCA
|DVT/PE||Pleuritic chest pain||– Post-op and bedridden|
– Highest risk in ortho pts
|US bilateral LE|
CT spiral chest or
|Heparin drip -> Warfarin|
IVC filter only – if no anticoagulation needed
|Myocardial Infarction||Silent MI||– Post-op|
- SEM cresc/decresc, louder w/ squatting, softer w/ valsalva. + parvuset tardus
- SEM louder w/ valsalva, softer w/ squatting or handgrip.
Mitral Valve Prolapse
- Late systolic murmur w/ click louder w/ valsalva and handgrip, softer w/ squatting
- Holosystolic Murmur radiates to axilla w/ LAE
- Holosystolic murmur w/ late diastolic rumble in kiddos
- Continuous machine like murmur-
- Wide fixed and split S2-
- Rumbling diastolic murmur with an opening snap, LAE and A-fib
- Blowing diastolic murmur with widened pulse pressure and eponym parade.
- see fluid >1cm on lateral decubitus -> thoracentesis!
- –If transudative, likely CHF, nephrotic, cirrhotic
- If low pleural glucose: 0.5Rheumatoid Arthritis
- If high lymphocytes: Tuberculosis
- If bloody: Malignant or Pulmonary Embolus
- –If exudative, likely parapneumonic, cancer, etc.
- –If complicated (+ gram or cx, pH < 7.2, glc< 60):
- Insert a chest tube for drainage.
- –Light’s Criteria -> transudative if:
- LDH < 200
- LDH eff/serum < 0.6
- Protein eff/serum < 0.5
- Spontaneous Pneumothorax -> subpleuralbleb ruptures ->lung collapse.
- –Suspect in tall, thin young men w/ sudden dyspnea (or asthma or COPD-emphysema)
- –Dxw/ CXR, Txw/ chest tube placement
- –Indications for surgery = ipsior contra recurrence, bilateral, incomplete lung expansion, pilot, scuba, live in remote area VATS, pleurodesis(bleo, iodine or talc)
- Lung Abscess -> usually 2/2 aspiration (drunk, elderly, enteral feeds)
- –Most often in post upper or sup lower lobes
- –Tx initially w/ abx -> IV PCN or clindamycin
- –Indications for surgery = abx fail, abscess >6cm, or if empyema is present.
Solitary Lung Nodule
- 1st step = Find an old CXR to compare!
- Characteristics of benign nodules:
- –Popcorn calcification = hamartoma(most common)
- –Concentric calcification = old granuloma
- –Pt< 40, <3cm, well-circumscribed
- –Tx: CXR or CT scans q2mo to look for growth
- Characteristics of malignant nodules:
- –If pt has risk factors (smoker, old), If >3cm, if eccentric calcification
- –Tx: Remove the nodule (w/ bronc if central, open lung biopsy if peripheral.
- inflammation -> impaired gas exchange, inflammation mediator release, hypoxemia
- –Sepsis, gastric aspiration, trauma, low perfusion, pancreatitis.
- 1.) PaO2/FiO2 < 200 (<300 means acute lung injury)
- 2.) Bilateral alveolar infiltrates on CXR
- 3.) PCWP is <18 (means pulmonary edema is non-cardio
- Mechanical ventilation w/ PEEP
A patient presents with weight loss, cough, dyspnea, hemoptysis, repeated pneumonia or lung collapse.
- MC cancer in non-smokers:
- Adenocarcinoma. Occurs in scars of old pneumonia
- Location and mets:
- Peripheral cancer. Mets to liver, bone, brain and adrenals
- Characteristics of effusion:
- Exudative with high hyaluronidase
- Patient with kidney stones, constipation and malaise low PTH + central lung mass:
- Squamous cell carcinoma. Paraneoplastic syndrome 2/2 secretion of PTH-rP. Low PO4, High Ca
- Patient with shoulder pain, ptosis, constricted pupil, and facial edema:
- Superior Sulcus Syndrome from Small cell carcinoma. Also a central cancer.
- Patient with ptosis better after 1 minute of upward gaze:
- Lambert Eaton Syndrome from small cell carcinoma. Ab to pre-syn Ca chan
- Old smoker presenting w/ Na = 125, moist mucus membranes, no JVD:
- SIADH from small cell carcinoma. Produces Euvolemic hyponatremia. Fluid restrict +/-3% saline in <112
- CXR showing peripheral cavitation and CT showing distant mets:
- Large Cell Carcinoma
|Achalasia||food gets stuck in the esophagus||LES fails to relax||Barium swallow – bird’s beak esophagus|
Manometry – tight LES
Dilation, Botox (inferior to Myotomy)
Mediastinitis: fever and leukocytosis
air in the mediastinum
2nd: Barium swallow
Best: EGD if others are negative
|Mallory Weiss||Self-limiting UGIB|
Weekend warriors with severe vomiting
2 large-bore IVs
Type and Cross
worse with laying flat and spicy foods
better with sitting upright and with antiacids
|lower esophageal sphincter fails|
|Alarm sxs: EGD with Bx||No alarm sxs: Lifestyle + PPI|
|Metaplasia||Increase PPI + Increase Surveillance|
|Adenocarcinoma||Esophagectomy, Nissen Fundoplication|
|upper 1/3: SCC – hot drinks, smoking|
lower 1/3: Adeno – GERD
|Barium Swallow (localizes cancer)|
EGD with Bx
|Resection – Esophagectomy|
- Dysphagia to liquids & solids
- Tx w/ CCB, nitrates, botox, or heller myotomy
- Assoc w/ Chagas dz and esophageal cancer.
Boerhaave’s Esophageal Rupture
- If hematemesis (blood occurs after vomiting, w/ subQ emphysema). Can see pleural effusion w/ ↑amylase
- Next best test:
- CXR, gastrograffin esophagram. NO endoscopy
- Tx: surgical repair if full thickness
Diffuse esophageal spasm
- Dysphagia worse w/ hot & cold liquids + chest pain that feels like MI w/ NO regurgitating symptoms.
- Tx w/ CCB or nitrates
- If progressive dysphagia/weight loss
- Carcinoma Squamous cell in smoker/drinkers in the middle 1/3. Adeno in ppl with long-standing GERD in the distal 1/3.
- Best 1sttest: barium swallow, then endoscopy w/ biopsy, then staging CT.
- Adeno most common. Especially in Japan
- – Krukenberg: Gastric Ca -> Ovaries
- – Virchow’s node: L supraclavicular fossa
- – Lymphoma: HIV
- – Blummer’s Shelf: METS felt on DRE
- – Sister Mary Joseph: Umbilical node
- – MALT-lymphoma: H-pylori
Other GI disorders
- –Mentriers = protein losing enteropathy, enlarged rugae.
- –Gastric Varices = splenic vein thrombosis.
- –Dieulafoy’s = massive hematemesis -> mucosal artery erodes into stomach
- MEG pain worse w/ eating. H.pylori, NSAIDs, ‘roids
- –Work up = Double-contrast barium swallow-punched out lesion w/ reg margins. EGD w/ bx can tell H. pylori, malign, benign.
- –Surgery if – Lesion persists after 12wks of treatment.
- If gross hematemesis unprovoked in a cirrhotic w/ pulmonary HTN.
- If in hypovolemic shock:
- do ABCs, NG lavage, medical tx w/ octreotide or SS. B
- balloon tamponade only if you need to stabilize for transport
- Tx of choice:
- Endoscopic sclerotherapy or banding
- *Don’t prophylactically band asymptomatic varices. Give BB.
- Epigastric pain worse after eating or when laying down, cough, wheeze, hoarse.
- Most sensitive test is 24-hr pH monitoring.
- Do endoscopy if “danger signs” present.
- Tx w/ behavior mod 1st, then antacids, H2 block, PPI.
- Acid reflux pain after eating, when laying down
- –Type 1 = Hernia Sliding. GE jxn herniates into thorax. Worse for GERD. Tx sxs
- –Type 2 = Paraesophageal. Abd pain, obstruction, strangulation -> needs surgery.
- Bad breath & snacks in the AM.
- Only contains mucosa
- Tx w/ surgery
Indications for surgery
- bleeding, stricture, Barrett’s, incompetent LES, max dose PPI w/ still sxs, or no want meds.
|Obstruction||Distended Abdomen||– Adhesion (previous surgery)|
– Hernias (no previous surgery)
|KUB (Xray) |
– dilation/air-fluid levels proximal to the obstruction
– collapsed bowel distal to that
SBO or LBO
|NG tube decompression|
MC nursing home
Nontender but very distended
– dilation of ENTIRE large bowel
– small bowel normal
|Colonoscopy r/o cancer|
|Paralytic Ileus||Days after surgery|
|Metabolic, K|| KUB (Xray) |
– small bowel and large bowel both distended
|LIFT procedure – Remove the fistula|
- -MEG pain better w/ eating
- –95% associated w/ H. pylori
- –Healthy pts< 45y/o can do a trial of H2 block or PPI
- –Dx: blood, stool, or breath test for H. pylori but endoscopy w/ biopsy (CLO test) is best b/c it can also exclude cancer.
- –Tx: PPI, clarithromycin & amoxicillin for 2wks. Breath or stool test can be test of cure.
- If MEG pain/ulcers don’t resolve
- –Best test: Syndrome Secretin Stim Test (find inapprop high gastrin)
- –Tx: Surgical resection of pancreatic/duodenal tumor
- –What else to look for: Pituitary and Parathyroid problems.
- A patient has bilious vomiting and post-prandial pain.
- –Pathophys: 3rd part of duodenum compressed by AA and SMA
- –Tx: SMA by restoring weight/nutrition. Can do Roux-en-Y
|Small Bowel Obstruction|| Colicky abdominal pain|
flatus and BM
Borborygmi – Absent
| Adhesions (If prev GI surgery)|
Hernias (if NO prev GI surgery)
| 1: Upright KUB (Xray) – air-fluid levels|
2: CT scan gastrografin po contrast
| Complete obstruction: Go to surgery|
Incomplete: NG Tube decompression….wait 3 days…go to surgery if no change
Peritoneal signs: surgery
|Hernias||Abdominal bulge|| Direct Hernias: Adults, transversalis, Inguinal hernias males|
Indirect Hernia: babies, patent processus vaginalis, inguinal ring, inguinal hernia
Femoral Hernia: women, under the inguinal ligament
Ventral Hernia: post-op, iatrogenic, failure of fascial plane
|Physical Exam|| Reducible: Elective repair|
Incarcerated: Urgent repair
Strangulated: Emergent repair
|Appendicitis|| Umbilical pain that radiates to the RLQ (McBurney’s point)|
|Surgery – laparoscopic appendectomy|
R sided fibrosis of the tricuspid valve
| produces serotonin|
metastasize to liver to produce sxs
| 5-HIAA in the urine|
|Acute Pancreatitis||epigastric pain that radiates to the back|
positional chest pain
|Increase lipase 3x||NPO|
No improvement: do CT scan
|Necrotizing Pancreatitis||Poor Ranson’s criteria|
|severe pancreatitis||CT scan|
Surgical drainage & Debridement
|Pancreatic Abscess||days after pancreatitis |
leukocytosis that fails to resolve
|pancreatic infection||CT scan||Abx|
|Pseudocysts||weeks after pancreatitis |
|fluid-filled vesicle |
not lined by endothelium
|CT scan||< 6cm, < 6 weeks: observe and wait|
6cm or > or > 6 weeks:
Percutaneous drain or
|Anal Cancer||anal receptive sex|
men with men
|SCC secondary to HPV||biopsy|
Assess HIV status
|Chemo and radiation (Nigro Protocol)|
Usually, resection is not needed
|Anal Fissures||Pain on defecation|
lasts for hours
fear of defecation
|tight sphincter||visual inspection||sitz bath|
lateral internal sphincterotomy
|Colon Cancer||Post-menopausal female or any male with iron deficiency anemia|
alternating bowel habits with changes in the caliber of the stool
|R sided bleed, but do not obstruct|
L sided do NOT bleed, but do obstruct
|Colonoscopy||CT scan to stage|
Chemo (FOLFOX, FOLFIRI)
|Familial Adenomatous Polyposis||1000s of polyps by 20 yo|
cancer by 30 yo
death by 40 yo
endothelial lined connection from any two organs
GI tract to anything (vagina, skin, bladder)
|probing||LIFT = Fistulotomy|
|Hemorrhoids||Dark blood on the toilet paper after BM|
|Internal: BLEED, but DONT hurt|
External: DONT bleed, but HURT
|Visual Inspection||High fiber diet|
Internal – Banded
External – Resection
|Pilonidal Cyst||Congenital Defect|
|Abscessed Hair follicle||clinical||incision and drainage |
resection of the cyst
|Polyp||asymptomatic: screening colonoscopy||Benign:|
|colonoscopy with biopsy||No polyp = 10 years|
Benign polyp = 5-7 years
|Ulcerative Colitis||bloody bowel movement plus weight loss|
associated with PSC, seronegative arthritis
|AI – Ashkenazi Jews|
|colonoscopy = continuous lesions|
biopsy = superficial inflammation
|resection (before cancer)|
can try monoclonal Ab anti-TNF
> 8 years from dx
mandatory annual colonoscopy
recommended ppx colectomy
|Arterial Insufficiency Ulcer||peripheral vascular disease|
– hairless leg
– decreased pulses
– scaly legs
ulcers at tips of toes…dry gangrene
|no blood circulating||ankle-brachial index|
|Compression Ulcer||bed-ridden patients who didn’t move|
out of bed
ulcers occur on heels and toes
|clinical||control blood glucose|
|Marjolin’s Ulcer||wound repeatedly healing and breaking down with a continuous draining tract|
Ulcer: ugly, deep, heaped margins
|punch biopsy||wide resection|
|Venous Stasis Ulcer||edema|
|no blood circulating||clinical||control disease: CHF/Nephrotic/Cirrhosis|
- Caused by impaired blood flow -> ischemia
- –Don’t culture will just get skin flora. Check CBC and blood cultures. Can mean bacteremia or osteomyelitis.
- –Can do tissue biopsy to rule out Marjolin’sulcer
- –Best prevention is turning q2hrs
- –Stage 1 = skin intact but red. Blanches w/ pressure
- –Stage 2 = blister or break in the dermis
- –Stage 3 = SubQdestruction into the muscle
- –Stage 4 = involvement of joint or bone.
- Stage 1-2: get special mattress, barrier protection
- Stage 3-4: get flap reconstruction surgery
- –Before surgery, albumen must be >3.5 and bacterial load must be <100K
- ↓Na = Gain of water
- –Check osm, then check volume status.
- –↑volume ↓Na: CHF, nephrotic, cirrhotic
- –↑volume ↓ Na: diuretics or vomiting + free water
- –Normal volume ↓Na: SIADH, Addisons, hypothyroidism
- –Treatment: Fluid restriction & diruetics
- –If hypovolemic: Normal Saline
- –When to use 3% saline: SalineSymptomatic (Seizures), < 110
- –What would you worry about: 110Central Pontine Myolinolysis
- ↑Na =Loss of water
- –Treatment: Replace w/ D5W or hypotonic fluid
- –What would you worry about: cerebral edema
Other Electrolyte Abnormalities
- ↓Ca = Numbness, Chvostek or Trousseau, prolonged QT interval.
- ↑Ca = Bones, stones, groans, psycho. Shortened QT interval.
- ↓K = Paralysis, ileus, ST depression, U waves.
- –Treatment: give K (kidneys!), max 40mEq/hr↑K
- ↑K = Peaked T waves, prolonged PR and QRS, sine waves.
- –Treatment: Give Ca-gluconate then insulin + glucose, kayexalate, albuterol, and sodium bicarb. Last resort = dialysis
|Urinary Retention||Decreased urinary output|
Urge to void
|In and Out cath |
|No Urine Output||no urine output||Kinked foley|
|Unkink and flush foley|
|Acute Renal Injury||-Reduced fluid intake (Nausea)|
-Increased fluid losses (vomiting and diarrhea)
-Urinary tract symptoms (BPH -prostatic disease obstruction
-Recent drug ingestion (Paracetamol overdose)
|1) Rise in serum creatinine of 23micromol/L/48hours|
2) Urine output <0.5ml/kg/hour for 6 hours
-Vomiting and diarrhea-Over diuresis with diuretics
-Burns (Excessive fluid loss through skin)
-Renal artery stenosis
|inadequate blood flow to perfuse the kidney (decreased renal perfusion)|
|Intra-Renal AKI||-Vasculitis (inflammation of blood vessels|
-Acute tubular necrosis
|Post-Renal AKI||-Retroperitoneal fibrosis|
-renal stone disease
-prostatic enlargement (BPH – benign prostatic hyperplasia)
|Obstruction to the renal tract (anywhere from the renal pelvis to the urethra)|
Fluid and Nutrition
- Maintenance IVFs: D51/2NS + 20KCl (if peeing)
- –Up to 10kg: 100mL/kg/day
- –Next 10 kgs: 50mL/kg/day
- –All above 20: 20mL/kg/day
- Enteral Feeds: best to keep gut mucosa intact and prevent bacterial translocation.
- TPN: indicated if gut can’t absorb nutrients 2/2 physical or functional loss.
- –Risks = acalculus cholecystitis, hyperglycemia, liver dysfunction, zinc deficiency, other ‘lyte probs