1. - All Biliary Stone related diseases cause fever, pain and jaundice with varying degrees, the Diagnosis of Cholangitis is based on the fact that it is a stone disease with an acute and sever bacterial infection. - Porcaline gallbladder can be seen an incidental finding KUB usu. with stones, and is a/w gallbladder-CA, thus Rx. elective cholecystectomy.
2. IF there is RUQ pain, or Jaundice((add LFT, PT, PTT,Bleeding time, INR, Amylase&lipase, CXR, KUB, U/S of the Abd.))
   1. + LFT
      1. Liver disease
   2. + Alk.Phos.
      1. Bile stone
      2. w/ Fever+
   3. Lipase is most specific & Sensitive
      1. Pancreatic
         1. Inv.CT to show extent of Disease
            1. Dx. ACUTE PANCREATITIS
            2. MILD edema =80% of pt. Rx is = GI rest(=NPO+NGT suction+Fluids(IV)) + morphine
            3. NECROTIC
            4. minimal or fever
            5. Rx. imipenem (IV)
            6. Large necrosis or abscess
            7. Rx. Surgery & imipenem(IV)
            8. Gall Stone or Cholangitis
            9. ERCP with sphincterotomy followed by cholecystectomy
            10. PSEUDOCYST
            11. most=self limiting w/in 6 weeks=Rx. is not needed
            12. not healed in 6 weeks or complicated=Rx. Surgery
   4. if a/w weight loss
      1. r/o pancreatic CA CT
         1. if mass is found excise surgically, do not do percutaneus aspiration to avoid CA seeding and spreading
3. ACUTE Abd.(( add ABC, NPO,IV access w/NS, CXR, KUB, Blood cross matching.=prep. for surgery))
   1. LLQ pain & tenderness
      1. Dx. Diverticulitis
         1. Inv. CT
            1. Rx. GI rest ( NGT+NPO+NS Fluid(IV))& Metronidazole (IV)+Ciproflxacin(IV)
   2. RUQ
      1. Dx. I.U/S, II.CT, III.ERCP IV.MRI
         1. stone in Gallbladder+ CHRONIC S/S
            1. Dx. Chronic Cholecystitis (Biliary Colic)
            2. Rx. Elective cholecystectomy
            3. Bile-salt induced diarrhea is seen 10% post-cholecystectomy, Rx. cholestyramine
         2. Gallstone+Gallbladder wall thickening more then 4mm+ PERI-Cholecystic fluid+ U/S-positive Murphy's Sign
            1. Dx. ACUTE CHOLECYSTITIS
            2. Rx. Ampicillin(IV) Gentamycin(IV)+ I.cholecystectomy with in 1-2days II. percutaneous cholecystostomy tube in seriously ill patients.
         3. Stone in Common Bile Duct(CBD)+ Dilated CBD > 8mm
            1. Dx. CHOLEDOCHOLITHIASIS
            2. Rx.ERCP with sphincterotomy
         4. normal OR Dilated CBD > 8mm
            1. Dx. ACUTE CHOLANGITIS (Bacterial infection)
            2. Rx. ERCP with sphincterotomy + IV fluids + Ampicillin(IV) Gentamycin(IV)
      2. Subtopic 3
   3. Subtopic 3
   4. Subtopic 4
4. Intermittent Abdominal Pain
   1. w/ DM
      1. w/ steatorrhea
         1. Dx. CRONIC PANCREATITIS(MCC alcohol)
            1. Inv. ERCP( show: irregular main duct, ductal dilation, and duct strictures) is better then CT
            2. mild
            3. Rx. NSAID, Insulin, & Replace pancreatic enzymes
            4. Strictures
            5. ERCP Sphincterotomy & stenting
            6. sever=OBstruction of GI or Bile, sever pain, r/o CA
            7. Surgery
      2. w/ liver disease, infertility and arthritis
         1. Dx. Hematochromatosis
            1. Rx. Phlebotomy
      3. w/ Risk of Coronary heart disease
         1. Dx. mesenteric ischemia
            1. Inv. I. Mesenteric U/S II .Splenichnic Angiogrophy
      4. Subtopic 4
   2. Subtopic 2
   3. Subtopic 3
5. w/ Respiratory S/S
   1. a/w back & shoulder pain
      1. Pluretic pain & Respiratory S.&S.
         1. Dx. Esophageal perforation (Borhave Syndrome)
            1. Inv. Esophageo-gram w/ water soluble contrast is better the, CT or barium swallow, do a CXR to asses the extent of lung involvement
            2. Rx: surgical repair+ drainage of mediastinum and pleural cavity (Nasogastric suction+drainage with tube thoracostomy)+Imipenem & cilastatin (Primaxin)
   2. Tracheo-esophageal Fistual
   3. GERD
6. Main Topic 3
   1. Subtopic 1
   2. Subtopic 2
7. Main Topic 6
8. Main Topic 7