Overview Snapshot A 49-year-old obese Hispanic female presents to a community physician late in the afternoon with progressively worsening yet constant RUQ pain that worsened after eating a fatty meal. She obtains a RUQ ultrasound scan, which reveals the presence of gallstones without pericystic fluid or wall thickening. The physician recommends ibuprofen for pain relief, increased fluid intake, minimal fatty food intake, and follow-up in two days for reevaluation of labs, including the patients bilirubin and amylase levels. Introduction Risk factors for cholesterol stones: Four F's Fat (obesity) Female (estrogen source - OCP) Forty Fertile (multiparity) impaired gallbladder emptying: starvation, diabetes (paresis), TPN rapid weight loss (due to rapid cholesterol mobilization and biliary stasis) terminal ileal resection or disease (e.g., Crohn's) Native American heritage (especially Pima Indians) Risk factors for pigment stones (calcium-based) cirrhosis biliary stasis (strictures, dilation, biliary infection) chronic hemolysis Presentation Symptoms gallstones are common and most are asymptomatic (80%) biliary colic is transient impaction of gallstone in cystic duct without evidence of infection steady, severe dull pain in epigastrium or RUQ for minutes to hours crescendo-decrescendo pattern possible presence of chest pain possible radiation to right scapula or shoulder no systemic signs or peritoneal signs frequently after fatty meal (secondary to cholecystokinin (CCK) release) or at night symptoms similar to colic can also be caused by spincter of Oddi dysfunction, which can be diagnosed with spincter manometry and treated with spincerterotomy via ERCP Evaluation Imaging first-line: RUQ ultrasound ERCP (endoscopic retrograde cholangiopancreatography) diagnostic: visualizes upper GI tract, ampullary region, biliary and pancreatic ducts therapeutic: treats common bile duct stones in periampullary region MRCP (magnetic resonance cholangiopancreatography) non-invasive compared to ERCP, but not therapeutic radiograph only valuable if positive because 15-20% of gallstones are radiopaque Labs most important labs for biliary pain total and direct bilirubin levels: for evidence of obstruction amylase: for evidence of gallstone pancreatitis CBC, electrolytes, LFTs Treatment Asymptomatic patients do not require cholecystectomy Pain control, rehydration during colic episode Sphincter of Oddi dysfunction presents similar to acute cholecystitis ERCP with sphincterotomy Elective laparoscopic cholecystectomy no evidence of benefit for delaying surgery patients at risk for cancer should have cholecystectomy Native Americans patients with imaging suggestive of porcelain gallbladder (gallbladder cancer) cholecystectomy for patients with recurrent biliary colic or evidence of pancreatitis
QUESTIONS 1 of 11 1 2 3 4 5 6 7 8 9 10 11 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI Blood, Plasma, Serum Reference Range ALT 8-20 U/L Amylase, serum 25-125 U/L AST 8-20 U/L Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL Calcium, serum (Ca2+) 8.4-10.2 mg/dL Cholesterol, serum Rec: < 200 mg/dL Cortisol, serum 0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h Creatine kinase, serum Male: 25-90 U/LFemale: 10-70 U/L Creatinine, serum 0.6-1.2 mg/dL Electrolytes, serum Sodium (Na+) 136-145 mEq/L Chloride (Cl-) 95-105 mEq/L Potassium (K+) 3.5-5.0 mEq/L Bicarbonate (HCO3-) 22-28 mEq/L Magnesium (Mg2+) 1.5-2.0 mEq/L Estriol, total, serum (in pregnancy) 24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL 28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL Ferritin, serum Male: 15-200 ng/mLFemale: 12-150 ng/mL Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250 pH 7.35-7.45 PCO2 33-45 mmHg PO2 75-105 mmHg Glucose, serum Fasting: 70-110 mg/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative stimuli: > 7ng/mL Immunoglobulins, serum IgA 76-390 mg/dL IgE 0-380 IU/mL IgG 650-1500 mg/dL IgM 40-345 mg/dL Iron 50-170 μg/dL Lactate dehydrogenase, serum 45-90 U/L Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL Osmolality, serum 275-295 mOsmol/kd H2O Parathyroid hormone, serume, N-terminal 230-630 pg/mL Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L Phosphorus (inorganic), serum 3.0-4.5 mg/dL Prolactin, serum (hPRL) < 20 ng/mL Proteins, serum Total (recumbent) 6.0-7.8 g/dL Albumin 3.5-5.5 g/dL Globulin 2.3-3.5 g/dL Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h Thyroxine (T4), serum 5-12 μg/dL Triglycerides, serum 35-160 mg/dL Triiodothyronine (T3), serum (RIA) 115-190 ng/dL Triiodothyronine (T3) resin uptake 25%-35% Urea nitrogen, serum 7-18 mg/dL Uric acid, serum 3.0-8.2 mg/dL Hematologic Reference Range Bleeding time 2-7 minutes Erythrocyte count Male: 4.3-5.9 million/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 12.0-16.0 g/dL Hemoglobin, plasma 1-4 mg/dL Leukocyte count and differential Leukocyte count 4,500-11,000/mm3 Segmented neutrophils 54%-62% Bands 3%-5% Eosinophils 1%-3% Basophils 0%-0.75% Lymphocytes 25%-33% Monocytes 3%-7% Mean corpuscular hemoglobin 25.4-34.6 pg/cell Mean corpuscular hemoglobin concentration 31%-36% Hb/cell Mean corpuscular volume 80-100 μm3 Partial thromboplastin time (activated) 25-40 seconds Platelet count 150,000-400,000/mm3 Prothrombin time 11-15 seconds Reticulocyte count 0.5%-1.5% of red cells Thrombin time < 2 seconds deviation from control Volume Plasma Male: 25-43 mL/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 19-31 mL/kg Cerebrospinal Fluid Reference Range Cell count 0-5/mm3 Chloride 118-132 mEq/L Gamma globulin 3%-12% total proteins Glucose 40-70 mg/dL Pressure 70-180 mm H2O Proteins, total < 40 mg/dL Sweat Reference Range Chloride 0-35 mmol/L Urine Calcium 100-300 mg/24 h Chloride Varies with intake Creatinine clearance Male: 97-137 mL/minFemale: 88-128 mL/min Estriol, total (in pregnancy) 30 wks 6-18 mg/24 h 35 wks 9-28 mg/24 h 40 wks 13-42 mg/24 h 17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 6-15 mg/24 h Osmolality 50-1400 mOsmol/kg H2O Oxalate 8-40 μg/mL Potassium Varies with diet Proteins, total < 150 mg/24 h Sodium Varies with diet Uric acid Varies with diet Body Mass Index (BMI) Adult: 19-25 kg/m2 Calculator ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M2.GI.71) A 46-year-old female presents with severe postprandial right upper quadrant pain. She has had similar symptoms off and on for the last several years with the pain remitting after approximately a day. She undergoes an abdominal CT scan which is shown in Figure A. Based on the imaging findings, this patient is at increased risk for which of the following conditions? Review Topic QID: 104862 FIGURES: A 1 Pancreatic carcinoma 0% (0/9) 2 Gallbladder carcinoma 89% (8/9) 3 Hepatocellular carcinoma 11% (1/9) 4 Aneurysm rupture 0% (0/9) 5 Echinococcal cyst rupture 0% (0/9) M2 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (M2.GI.62) A 30-year-old G3P3 female presents with a history of multiple episodes of right upper quadrant (RUQ) pain following fatty or heavy meals for the past year. The pain occurs in waves and resolves on its own. It is deep and achey in quality. She has a history of hypertension. Her past medical history is significant for prior cholecystectomy and splenectomy, as well as two episodes of pancreatitis for which no cause was identified. Physical exam reveals an obese female in no distress, and tenderness to deep palpation in the RUQ. LFTs are elevated to twice the upper limit of normal. MRCP shows a dilated common bile duct and no other abnormalities. What course of action is most likely to lead to the correct diagnosis? Review Topic QID: 104853 1 Blood test for anti-mitochondrial antibody 25% (2/8) 2 Spincter of Oddi manometry 75% (6/8) 3 Upper GI series 0% (0/8) 4 Hydrogen breath test 0% (0/8) 5 Capsule endoscopy 0% (0/8) M2 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (M2.GI.10) For which of the following patients is an abdominal ultrasound the most appropriate first diagnostic test? Review Topic QID: 104801 1 69-year-old female smoker with 10 pound weight loss and change in sputum 0% (0/68) 2 64-year-old male with known prostate cancer presenting with lower extremity weakness and loss of bladder control 1% (1/68) 3 58-year-old male with Marfan syndrome presenting with acute onset chest pain radiating to the back 6% (4/68) 4 28-year-old female with Crohn's disease presenting with 5 hours of abdominal pain, constipation, and nausea 0% (0/68) 5 48-year-old mother of 3 with a history of right upper quadrant pain following fatty meals 91% (62/68) M2 Select Answer to see Preferred Response PREFERRED RESPONSE 5