PANCE Blueprint GI and Nutrition (9%)

Presentation:

• 5 Fs: Female, Fat, Forty, Fertile, Fair
• (+) Murphy's sign (RUQ pain with GB palpation on inspiration)
• RUQ pain after a high-fat meal
• Low-grade fever, leukocytosis, jaundice

Diagnosis:

• Ultrasound is the preferred initial imaging - gallbladder wall >3 mm, pericholecystic fluid, gallstones
• HIDA is the best test (Gold Standard) - when ultrasound is inconclusive
• CT scan - alternative, more sensitive for perforation, abscess, pancreatitis
• Labs: ↑ Alk-P and ↑ GGT, ↑ conjugated bilirubin
• Porcelain gallbladder = chronic cholecystitis
• Choledocholithiasis = stones in common bile duct - diagnosed with ERCP (gold standard)

Treatment: Cholecystectomy (first 24-48 hours)

Organisms: E. coli, Enterococcus, Klebsiella, Enterobacter

Presentation:

• Charcot’s triad: RUQ tenderness, jaundice, fever
• Reynold’s pentad: Charcot’s triad + altered mental status and hypotension

Diagnostic studies:

• Initial imaging: Ultrasound
• Best: ERCP

Treatment:

Aggressive care and emergent removal of stones, Cipro + metronidazole

• Antibiotics, fluids, and analgesia.
• ERCP to remove stones, insert a stent, repair the sphincter
• Cholecystectomy (performed post-acute)

Primary sclerosing cholangitis

• Jaundice and pruritus
• Associated with IBD, cholangiocarcinoma, pancreatic cancer, colorectal cancer

• Stones in the gallbladder, pain secondary to contraction of gall against the obstructed cystic duct
• Asymptomatic (most), symptoms only last few hours
• Biliary colic—RUQ pain or epigastric
• Pain after eating and at night
• Boas sign—referred right subscapular pain
• RUQ ultrasound - high sensitivity and specificity if  >2 mm. CT scan and MRI

TX: Asymptomatic—No treatment necessary

• Elective cholecystectomy for recurrent bouts