1. - All Biliary Stone related diseases cause fever, pain and jaundice with varying severity, the Diagnosis of Cholangitis is based on the fact that ALL 3 S/S are presenting at the same time. - Porcaline gallbladder can be seen an incidental finding KUB usu. with stones, and is a/w gallbladder-CA, thus Rx. elective cholecystectomy. -During inflammation Neutrophils increasing in number & neutrophils tend to be younger, as they are being released more quickly(this is called a left shift) seen for eg in appendicitis, & cholecystitis.
  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 (Biliary decompression)+ IV fluids + Ampicillin(IV) & Gentamycin(IV)
    3. RLQ
      1. Anorexia & left shift
        1. Dx. of appendicitis is CLINICAL
          1. Inv. CT to confirm
          2. Rx. Laparoscopic Appendictomy
          3. complications
          4. Subtopic 1
          5. pregnancy= Rx. surgery w/in 24 hours
          6. 1st Trimester
          7. Abortion
          8. 2nd Trimester
          9. Premature delivery
          10. 3ed Trimester
          11. Fetal Death & pylephlebitis of portal vein
    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, maybe a/s metabolic acidosis
        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. w/ constipation for days=do obstruction series x-ray
    1. more air in the proximal small bowel, and less in the distal small bowel
      1. Dx. Small bowel obstruction
        1. Rx. I. Bowel rest, correction of Electrolyte disturbance.if no improbmentn in 12-24hours->II. Surgery
    2. part of the colon has air, the other part has less air
    3. no air in distal colon, S/S of peritonitis, or strangulation
      1. Dx. complete obstruction
        1. Rx. Surgery
  7. Flank Pain
    1. Urinalysis = Hematuria (frank or microscopic)
      1. upper ureter=flank pain, lower ureter= pain radiates to the ipsilateral groin
        1. Dx. Renal Stone
          1. Inv. CT: Distal ureter (close to bladder) compared to a proximal ureteral stone (close to kidney)
          2. 5mm or less=likely to pass with no further Rx
          3. more then 5mm=less likely to pass & usu. need intervention
          4. proximal & 5-10mm
          5. Rx. Extracorporeal shock wave lithotripsy (ESWL)
          6. proximal & more then 10mm
          7. Rx. Flexible uretero-scope with laser lithotripsy
          8. if there are S./S of infection
          9. Rx. ER percutaneous Nephrostomy & antibiotics
          10. Rx. Hydration (IV) & NSAID( eg ketorolac(IM)) are as good if not better the opioids
    2. Urinalysis =Pyuria(=WBC cast)
      1. Dx. Pyelonephritis
        1. Subtopic 1