risk factors for gallstones
- FH, fair, fat, female, fertile, forty!!
- female
- age
- American indians
- obesity
- rapid weight loss
- CD
- pregnancy
- oral contraceptives
protective factors for gallstones
- low carb diet
- physical activity
- cardiorespiratory fitness
- coffee
- Mg and polyunsaturated fats
- high fiber diet
- ASA and NSAIDs
what is ascending cholangitis- lab
- infection of biliary tract secondary to bile duct obstruction or bile stasis
- hyperbilirubinemia, leukocytosis, transaminitis, alk phos elevation
asc cholangitis- causes
-choledolithiasis, pancreatic/biliary neoplasm, postop strictures, choledocal cysts
asc cholangitis- organisms involved
Gram neg- E coli (most common), Klebsiella pneumoniae, Enterobacter
- Gram +- Enterococcus
- Anaerobes- Bacteroides fragilis, Clostridia
Charcot’s Triad
- Jaundice
- fever (>102F)
- RUQ pain
reynold’s pentad
(assoc with morbidity and mortality!!)
- Charcot’s triad
- mental status changes
- hypotension
treatment of asc cholangitis
- Urgent ERCP- sphincterotomy with stone removal or stent placement
- abx- aerobes and anaerobes
- supportive care like IVF (treat sepsis and shock)
Abx for treating cholangitis
Ampicillin-sulbactam
-ceftriaxone PLUS metronidazole
cholangitis- what tests should be ordered?
- AST/ALT, Alk phos, fractionated bilirubin, amylase/lipase (pancreatitis from choledocholithiasis vs post ERCP pancreatitis)
- pre-procedure INR
- follow up on blood cultures and bile cultures
complications post ERCP
- pancreatitis
- asc cholangitis
- less commonly- hemobilia, perforation, bile seaks
Mirizzi syndrome
- common hepatic duct obstruction caused by an extrinsic compression from an impacted stone in the cystic duct
- there may be a cholecystoenteric fistula- when a stone is impacted in cystic duct- causes narrowing of common hepatic duct- can lead to a cholecysenteric fistula
TNF alpha inhibitors- used for? SE
- treat infl conditions
- quality of life improving for many pts
- injectable or infused
- SE- infections!!!, cutaneous reactions, malignancy, induction of autoimmunity
TNF alpha inhibitors- annual screening; lab screening
- PPD, hepatitis panel, dermatology exam
- CBC with differential, CMP every 2 months
diaphragmatic excursion
- distance b/w level of dullness on full expiration and level of dullness on full inspiration
- normal= 3 to 5.5 cm
bronchophony
“99”- spoken words become louder and clearer
egophony
“ee” sounds like an A
whispered pectoriloquy
-whispers are heard louder and clearer
iliopsoas m test
- flex hip against resistance- inc abd pain!!
- irritation of the psoas m from infl of the appendix
obturator m test
- flex pts right thigh at hip, knee bent, rotate leg internally at hip- right hypogastric pain!!
- irritation of the obturator m from an inflamed appendix
when do you suspect choledocholithiasis on US?
- common bile duct > 6 mm
- elderly or post cholecystectomy- can get up to 10 mm
what do you consider when giving a biliary pt opioids?
- NSAIDs are preferred, but opioids can be given if NSAIDS are contraindicated or pain is uncontrolled
- inc sphincter of Oddi pressure- can worsen the problem and cause more pain- but insufficient data to suggest that morphine should be avoided!!!
Systemic Inflammatory Response Syndrome
2 of the following:
- T > 38 (100.4)
- HR > 90
- RR > 20 or PaCO2 < 32
- WBC > 12,000
Sepsis; severe sepsis
- sepsis -systemic response to an infection- 2 or more SIRS criteria
- severe sepsis- organ dysfxn, hypoperfusion/hypotension
