Q9 Gastro Quiz 2

Shellfish IgM antibodies to hepatitis A (HAV) are indicative of recent or acute infection. HAV can be acquired via contaminated shellfish. Hepatitis A is an ssRNA picorna virus that accounts for 30-45% of acute viral hepatitis. It is transmitted via the fecal-oral route, through contaminated food, water, and shellfish. The patient in the question stem has also been immunized against hepatitis B, as evidenced by her positive Anti-HBsAg serology.

A 30-year-old woman presents to your office with decreased appetite, malaise, and fever. Serologic tests reveal positive Anti-HBsAg and Anti-HAV IgM antibodies. Which of the following is most likely responsible for this patient's presentation? 1. Needlestick 2. Unprotected sex 3. Shellfish 4. Chronic hepatitis 5. Acetaminophen overdose

It may improve with calcium chelators Yhis patient's clinical presentation is consistent with hemochromatosis. Iron chelators such as deferoxamine, not calcium chelators, are used as treatment for this condition.

A 48-year-old man with a history of diabetes mellitus presents to his primary care physician with lethargy, joint pain, and impotence. Lab evaluation is notable for a ferritin of 1400 ug/L (nl <300 ug/L), increased total iron, increased transferrin saturation, and decreased total iron binding capacity. All of the following are true regarding this patient's condition EXCEPT: 1. It may lead to a decline in cardiac function 2. It may improve with serial phlebotomy 3. It may improve with calcium chelators 4. It is associated with an increased risk for hepatocellular carcinoma 5. It results in skin bronzing

His liver disease is reversible if appropriate lifestyle changes are enacted The gentleman in the question stem has been incidentally found to have alcoholic steatosis (i.e. fatty liver disease), which is a reversible condition that has the potential to completely resolve with alcohol cessation.

A 45-year-old gentlemen with hypertension, hyperlipidemia, depression, and alcohol abuse presents to the emergency room complaining of right lower quadrant pain that started approximately 12 hours prior to presentation. Since that time he has been unable to hold down any food or liquids. A CT scan is obtained and the report indicates acute appendicitis and early stage liver damage. Liver enzymes are as follows: AST 217, ALT 91. The man is taken to the operating room, where an uneventful laparoscopic appendectomy is performed. Upon discharge, the patient is referred to a gastroenterologist to discuss the prognosis of his liver disease. Which of the following outcomes is most likely discussed with the patient? 1. His liver disease is acute and will spontaneously resolve without intervention 2. His liver disease is reversible if appropriate lifestyle changes are enacted 3. His liver disease is reversible if appropriate medication is administered 4. His liver disease is irreversible but progression can be slowed with interferon therapy 5. His liver disease is irreversible and will continue to progress until he receives a liver transplant

HBsAg, HBeAg, Anti-HBc (IgM) HBeAg is a marker of viral replication and increased infectivity of hepatitis B virus (HBV). The presence of HBsAg, the surface antigen of HBV, indicates HBV infection. Anti-HBs is the antibody to HBsAg and indicates immunity to HBV. Anti-HbC IgM indicates acute/recent infection while anti-HbC IgG indicates prior exposure or chronic infection. HBeAg indicates active viral replication and therefore high transmissibility. Anti-HBe is the antibody to the E antigen and indicates low transmissibility.

A 47-year-old female presents to the health clinic because of recent changes to her health. She states that over the past week she has experienced fatigue, weakness, fever, and nausea. This morning she became very concerned when her partner told her that she "looked yellow". On exam, you note jaundice. On questioning, she admits to several sexual partners with whom she does not use protection. The physician orders blood work which looks for several serological markers. The presence of which of the following combinations of serologic markers would indicate the highest risk of transmissibility of this patient's infection? 1. HBsAg, HBeAg, Anti-HBc (IgM) 2. Anti-HBe, Anti-HBc (IgM) 3. HBsAg, Anti-HBe, Anti-HBc (IgG) 4. Anti-HBs, Anti-HBe, Anti-HBc (IgG) 5. Anti-HBs

AFP Serum alpha-fetoprotein (AFP) is the most important tumor marker elevated in many patients with hepatocellular carcinoma (HCC). Development of HCC is a major concern in individuals with cirrhosis and chronic hepatitis. Most individuals with HCC will be asymptomatic. Potential symptoms include weight loss, abdominal discomfort, a palpable mass, or worsening signs of portal hypertension (such as ascites).

A 52-year-old female with history of cirrhosis secondary to long-standing alcohol abuse visits her physician to discuss a 15-pound weight loss over the last 6 months. She reports early satiety, jaundice and vague abdominal discomfort. Her ascites, generally stable and small, has worsened in the last 3 weeks. Which of the following is the most appropriate serologic test to order at this time? 1. AFP 2. CA19-9 3. CA125 4. PSA 5. CEA

Choledocholithiasis

A pt presents with *Upper abdominal pain, jaundice, fever/chills*, upper abdominal/epigastric/RUQ tenderness, (+)Courvoisier sign and jaundice. What do you suspect?

Pancreatic Cancer

A pt presents with *Weight loss, abdominal pain, jaundice occurring together*; anorexia, GI bleeding, pain in mid-epigastric region/LUQ pain radiating to the back, boring, <night. What do you suspect?

Hemochromatosis

A pt presents with chronic fatigue, abdominal pain, *athralgias*, *infertility/amenorrhea*, ED, arrhythmias, hypopituitarism, *unexplained elevated and asx ALT/AST*, and *bronzing of the skin*. What is your most likely Dx?

Hepatic cirrhosis

A pt presents with hepatic sx (jaundice, fatigue, pruritus, ascites), malabsorption, spider nevi, caput medusa, gynecomastia; fluid wave, blunt liver/hard/shrunken. What do you suspect?

Hep C

A pt presents with the following sx: *urticaria, angioedema or acute arthritis* sx. fatigue, anorexia, weakness, joint pain, jaundice, rash, HSM. They report being an IV drug user. What is your most likely Dx?

Hep A

A pt presents with: *Prodromal flu-like illness* Anorexia, fatigue, N/V, fever, LAO *Chronic smokers disgusted by cigarettes* *Jaundice* *Dark urine* May also see steatorrhea, arthralgia, urticaria PE: *liver tender to palpation* What do you suspect?

Hepatitis B

A pt presents with: *Serum sickness-like syndrome* (may develop during the prodromal period) Anorexia, nausea, jaundice, and right upper quadrant discomfort Symptoms and jaundice generally disappear after one to three months Some patients have prolonged fatigue even after normalization of serum ALT/AST What do you suspect?

Tx glucose intolerance and management of obesity (*Metformin*, Glitazone, Pioglitazone, Incretin mimetics), weight loss of 10% can reduce LFTs, avoid alcohol, liver transplant

What is allopathic tx for NAFLD?

Pegylated Interferon, Ribavirin No vaccine yet!

What is allopathic tx for chronic Hep C?

Intravenous antibiotics, fluids Parenteral nutrition Cholecystectomy via laparotomy

How would expect an allopathic physician to tx cholecystitis?

Depends on severity *Referral to ER/gastro/internist SHOULD occur* (This is a MEDICAL EMERGENCY. REFER TO THE ER!) Aid post-recovery Difference between this and cholelithiasis is SEVERITY of presentation, especially FEVER AND CHILLS. This sign should NOT be ignored!

How would you tx Choledocholithiasis?

Avoid alcohol and cigarette smoking Diet: whole foods, organic Modify pollution exposure - HEPA filters, etc. *SAMe* *Zinc* 100 mg po QD x 7 days to reduce unconjugated bilirubin levels *Vit C* 4 gm QD, *Vit E* 800 IU QD - *Antioxidant support* Hepatoprotective herbs

How would you tx Gilbert's disease?

Abstinence from alcohol, smoking Diet: no animal products Digestive enzymes: for enzyme replacement and pain control, esp. *LIPASE* Herbs: Anti-inflammatory, Bitter herbs, anti-fibrotics STAY ON pancreatic enzymes STAY ON high dose antioxidants

How would you tx chronic pancreatitis?

Genetic counseling, *phlebotomy*, oral iron chelation (Deferasiox, deferoxamine), avoid iron cookware, reduce iron-rich food (red meat, leafy greens), avoid alcohol/fruit juice and Vitamin C supplements. Tannin intake *Black tea* (camellia sinensis): blocked 79-94% iron absorption *Peppermint* tea: 84% Cocoa: 71% (Drink with meal)

How would you tx hemochromatosis?

- Diet Stop smoking, *drinking* Clean Diet *Increase liver foods*: beets, artichokes, cauliflower, radish, bitter greens, broccoli Most proteins should be vegetable based (50%) Consider low iron diet High water intake Avoid hepatotoxic drugs Constitutional Hydrotherapy Castor oil packs - Nutrients: Vitamin C, Selenium, Carotenoids, Glutathione, SAMe, NAC, EGCG, curcumin, boswellia, quercitin, ALA, vitamin E, Zinc (best for hep tx: *Selenium (NAC), Silybum (milk thistle), and ALA*) Phosphatidylcholine (Glycine, taurine) Anti-viral botanicals: lauricidin, olive leaf, larch, glycyrrhiza, lmatium, Melissa Hepatoprotectives: silybum, taraxacum, chelidonium, schisandra, Liv 52 Antioxidants/Anti-inflammatory EGCG - green tea Curcumin 500 mg TID Boswellia, Quercitin *ALA, Vit E* Lipotropics Acupuncture: Condition of Damp Heat

How would you tx hepatitis?

Avoid alcohol ox bile, digestive enzymes, MCT oils/butters low protein diet AA therapy (L-ornithine/L-aspartate increases ability ot make glutamine) castor oil packs, *High dose antioxidants* (*ALA, selenium*, NAC, vitamin C, glutathione) Botanicals: *antifibrotics (schisandra*, centella, salvia, colchicum, astragalus, gingko, resveratrol) *hepatoprotective (Silybum)* homeo (phos, sulphur, curprum)

How woulf you tx hepatic cirrhosis?

Resolved acute HCV or acute HCV with low viremia levels

If a pt has + Anti-HCV Ig's and negative HCV RNA, what do you suspect?

Acute/Chronic Hep C Infection

If a pt has + Anti-HCV Ig's and positive HCV RNA, what do you suspect?

Acute HCV (early), CHC, false positive

If a pt has - Anti-HCV Ig's and positive HCV RNA, what do you suspect?

*A-fetoprotein - elevated in 75-90%* of patients, though consider pancreatic cancer (Serum levels > 500 mcg/ml diagnostic in high risk patients; Normal 10-20 mcg/ml; *High ranges from Hep B (3200 mcg/ml) HCC in 95%*) - If alfa fetoprotein is elevated, follow up with a liver biopsy *Des-gamma-carboxy-prothrombin (PIVKA II)* and other serologic markers used in conjunction with AFP to strengthen diagnostic value CBC - *pancytopenia* CMP - *hyperbilirubinemia, hypoalbuminemia* US, CT and/or MRI depending on size of tumor

If you suspect HCC, what labs/imaging would you order?

High: total bilirubin, ALP, GGT, PT Low: Vit D3, Vit K Imaging: US, CT, MRI, PET, cholangiograpy

If you suspect biliary cancer, what labs/imaging would you order? What would you expect?

when a patient has at least *3 of the following 5* conditions: *FPG ≥ 100* mg/dL *BP ≥ 130/85* mm Hg *TG ≥ 150* mg/dL *HDL-C < 40* mg/dL in *men* or *< 50* mg/dL in *women* *Waist circumference ≥ 102 cm* (40 in) in *men* or *≥ 88* cm (35 in) in *women*

What is metabolic syndrome?

requires a response to cholecystectomy, with no pain recurrence for at least 12 months

What is required for a definitive dx of functional GB disorder?

- Normal ALT levels - Psychiatric disorders - Decompensated cirrhosis - Hx kidney transplant - AI diseases - Active IV drug users - Active EtOH users - HCV with HIV

Who should you caution with tx for Chronic Hep C?

*Abdominal US* - 98% sensitive CBC - increased WBC with infection. Order STAT AST/ALT, GGT Bilirubin Alk Phos Lipase/Amylase Xray no longer used due to false negatives and radiolucent (cholesterol) stones

You suspect Cholelithiasis, what labs/imaging would you order?

Anytime there is a fever present, definite clue to refer Pancreatitis: tachycardia, muscle cramps, clammy, nausea, Grey Turner or Cullen's, fatty stools, mild jaundice Cholecystitis: sharp, sudden pain with fever Courvosier sign, Murphy's Sign

What are Warnings signs for patients with abdominal symptoms (refer to ER)?

Avoid alcohol, liver transplant

What are allopathic tx options for hepatic cirrhosis?

*Elevated GGT* (usually < 100) *Macrocytosis* *Elevated serum AST* (usually < 500 U/L) *Elevated serum ALT* (usually < 200 U/L) *AST:ALT ratio > 2* *Total bilirubin: GGT ratio > 1* staging - fatty liver, hepatitis, cirrhosis

What are lab findings in ALD? What would a biopsy show?

Fibrotest/Fibrosure

What are non-invasive alternatives to biopsy for pts with hepatic cirrhosis?

Peripheral signs: *Spider nevi, Caput medusae* *Portal hypertension*: Ascites, Edema, Splenomegaly Esophageal varices *Advanced cirrhosis/fibrosis*: Encephalopathy, Severe infections - peritoneal signs Poor synthetic function - *bleeding*

What are red flag findings on PE if you suspect ALD?

Presence of *HCV RNA in blood > 6 mos* (Measure progress of treatment by assessing viral load) *Elevated ALT/AST > 6 mos* (ALT >>> more than AST)

What are the dx criteris for chronic Hep C?

*Destruction of hepatic cells* with *replacement of fibrotic tissue and nodule regeneration* (scarring) Impairs liver function

What are the effects of hepatic cirrhosis?

Alcoholic fatty liver - few clinical findings Alcoholic Hepatitis (mild to severe) AST elevated more than ALT Bilirubin elevation but less than 5 mg/dL INR elevation Neutrophilia Ascites Chronic Hepatitis with fibrosis or cirrhosis

What are the stages of ALD?

HBV, HCV, Leptospirosis, Rocky Mountain spotted fever, drug reactions (acetaminophen), A/I hep, alcoholic hep, NASH, sclerosing cholangitis

What are your differentials for Hep A?

HCC

What condition presents with Right-sided upper quadrant pain, early satiety, in the late stage causes metastasis, weight loss, fever, LAO, possibly palpable mass in abdomen

Pueraria lobata var montana (*Kudzu* root) in glycerite

What herb helps with alcohol cravings?

An *Autosomal recessive* genetic condition that is benign *UGT1A1 variant* - affected *glucuronyl transferase* inefficiently conjugates bilirubin, resulting in largely *harmless accumulation of unconjugated bilirubin* *Mild elevation of serum bilirubin* levels (total and indirect)

What is Gilbert's Disease?

An *autosomal recessive* genetic condition (HHC1) that leads to the *accumulation of iron* (total body iron *>15g*)

What is Hemochromatosis?

Supportive Anti-virals, nucleoside treatment unsupported in literature for acute Hep B Treatment only for fulminant hepatitis

What is allopathic tx for Hep B?

HbsAg+ > 6 months Serum HBV DNA > 10 (5th) copies/ml Persistent or intermittent elevation of ALT Liver biopsy shows hepatocyte damage

What is the diagnostic criteria of Chronic Hep B?

*Chronic infection with Hep B & C* (80-90%), alcoholism (10% w/ cirrhosis), obesity, DM, Aflatoxins

What is the etiology of Hepatocellular Carcinoma(HCC)?

Elevated AST/ALT - if > 6 months = chronic HCV Elevated Alk Phos, GGT HCV antibodies + by 3 mos HCV RNA (PCR) indicates acute HCV infection (Most sensitive and specific test) Liver biopsy for staging (Ishak Modification for Grading)

What labs would you expect to see in a HepC pt?

*HBV serology* *Serum ALT/AST* (Persistent elevation of ALT for > 6 mos indicates a progression to chronic hepatitis) Serum bilirubin Serum prothrombin (Prognosis) Hepatitis D serology

What labs would you order if you suspected Hep B?

*Serum Ferritin - best screening test* (> 500 ng/ml due to iron overload) Serum transferrin CRP to assess inflammation Biopsy not necessary to dx if sx mild

What labs/imaging would you order if you suspected Hemochromatosis?

ALT/AST normal or increased ALP normal or increased *GGT increased* *albumin decreased* *PT prolonged* *CBC*: *leukopenia, thrombocytopenia, normocytic/macrocytic anemia* Imaging: *fibroscan* or liver biopsy

What labs/imaging would you order if you suspected hepatic cirrhosis? What would you expect?

Icterus

What phase of Hep A lasts 1-3 weeks (can last 12 weeks) with No fever. Pale stools and dark urine, dehydration, hepatomegaly/tenderness

Prodromal

What phase of Hepatitis A lasts 10 days with flu like symptoms like malaise, fatigue, RUQ pain, myalgia

Close personal contact with infected person Child day care center Mental asylums Traveling to foreign countries Contact with sewage Work with primates International travel

What populations are at highest risk for Hep A?

People born in Asia or Africa where HepB is endemic Men who have sexual encounters with other men IV drug users Hemodialysis patients All pregnant women Patients receiving chemo or other immunosuppressive therapy Those who live with or have sex with someone with Hep B HIV infected Sexually promiscuous individual—more than 1 sex partner in 6 month period.

What populations are at highest risk for Hep B?

*Total bilirubin elevated* (~10) *Elevation of both AST : ALT < 1* Positive HAV Serology *Anti-HAV IgM (acute)*, *IgG(resolved)*

What would expect in the labs of a pt you suspect is infected with HepA?

High HBeAg and HBV DNA in serum—but no evidence of active liver disease as manifested by lack of symptoms, normal serum ALT concentrations, and minimal changes on liver biopsy

What would you expect in the serology of Chronic Hep B in the replicative phase?

Hepatitis B Surface Antigen (HBsAg): current infection. in serum several weeks before sx appear - presence of this means they are potentially infectious Hepatitis B E Antigen (HBeAg): active infection (HIGH INFECTIVITY) Hepatitis B Surface Antibody: recovery or immunity Hepatitis B e-Antibody (HBe or HBeAb): inactive virus (generally) Hepatitis B Core Antibody (HBc or HBcAb): present or past infection (IgM: acute, IgG: chronic, IgG with anti-Hbs = resolved infection) first to appear HBV DNA: measure of virus activity

You pt asks you to explain Hep B blood testing. How would you explain the serology?

*Ferritin (best marker)* (predictor of inflammation in NAFLD) Fasting serum glucose, insulin, and post-prandial glucose and insulin Lipid panel (TGs likely elevated) C-peptide CMP - ALT/AST *AST: ALT ratio is usually less than 1* (ALT is higher) *ALT & AST from normal to 2-5 x normal* *Alk Phos may be 2-3 x normal* GGT Imaging U/S of abdomen (easy, cheap, fast) Liver biopsy: GOLD STANDARD for definitive diagnosis but not recommended routinely (high risk for hemorrhage) Fibrospect/Fibrosure/Fibroscan

You suspect NAFLD, what labs/imaging will you order?

chronic hemolytic states

What do black pigment stones indicate?

cholestasis and biliary infection

What do brown pigment stones indicate?

AST:ALT >1

What is AST:ALT ratio in alcoholic liver damage?

Biliary cancer

A pt presents with Hyperbilirubinemia, jaundice, darkened urine, pruritus, RUQ abdominal discomfort, nausea, anorexia, Weight loss, fatigue, malaise, night sweats if advanced. What do you suspect?

Cholelithiasis

A pt presents with Biliary Colic, RUQ pain/epigastric pain that *radiates to the right scapula* or back that occurs Post-prandial (especially with *fatty foods* - w/in an hour, lasts 1-5 hours and peaks at midnight. They report the pain comes in waves and lasts 30 min to 5 hours. They deny change with position, amelioration from passing gas or BM. During the PE you note *lack of fever, tachycardia, diaphoresis* and *Murphy's sign negative*. What is your most likely Dx?

NAFLD

A pt presents with Fatigue/malaise, Vague RUQ pain, the *liver isn't sore or painful*, BMI>30; (Advanced cases of cirrhosis may show palmar erythema, ascites, spider angiomatas, etc. (end stage signs of liver failure);what do you suspect?

Elevated alkaline phosphatase This patient presenting with recurrent bouts of abdominal pain is concerning for biliary colic. The progression of symptoms to include pruritus, acholic stools, jaundice, and an ERCP showing a common bile duct stone would most likely manifest with a cholestatic pattern such as elevated alkaline phosphatase, total bilirubin, and gamma-glutamyl transferase. Choledocholitiasis, or obstruction of the biliary tree by a gallstone, is a common complication of cholelithiasis. Incidence of choledocolithiasis occurs in about 10-15% of individuals with gallbladder stones. Risk factors are similar to those of gallbladder stones, mainly the 5 F's of being female, forty (middle age), fat (obesity), fertile (estrogen increases risk), and presenting with flatulence (acholic stools and hyperbilirubinurea). As mentioned above, laboratory studies will demonstrate a cholestatic pattern, and definitive diagnosis is readily made with ERCP or magnetic resonance cholangiopancreatography (MRCP).

A 32-year-old female presents to the emergency department with abdominal pain and new onset itching all over. The patient has experienced recurrent abdominal discomfort, but was unable to get care due to lack of insurance. More recently, she has noticed the onset of pale-tan colored stools, and dark yellow urine. Vitals are T 101.0 F HR 93 bmp BP 126/93 mmHg RR 15 rpm SpO2 98% On physical exam, sclera are notably icteric. Abdominal exam demonstrates right upper quadrant and epigastric tenderness without guarding or rebound. Endoscopic retrograde cholangiopancreatography (ERCP) is shown in Figure A. Which of the following lab findings are most likely present? 1. Elevated AST and ALT 2. Elevated indirect billirubin 3. Elevated alkaline phosphatase 4. Elevated Anti-mitochondrial antibodies 5. Elevated Lipase

Hypertriglyceridemia This patient is experiencing an episode of acute pancreatitis. Hypertriglyceridemia should be very high on the differential when a patient denies alcohol use, there is no evidence of cholelithiasis, and has xanthomas on physical examination.

A 37-year-old woman with a past medical history diabetes, high cholesterol, hypertension and anxiety complains of rapid-onset, mid-epigastric pain with radiation to the back. She states that she has had a few of these episodes in the past, but this is the worst so far. Her pain is somewhat relieved by sitting forward. Physical examination notes epigastric tenderness without guarding or rebound and xanthomas were noticed on her arms. Laboratory studies show elevated amylase and lipase. She denies use of alcohol, tobacco, and illicit drugs. A RUQ ultrasound was performed and found to be negative and total and direct bilirubin are normal. Urine toxicology returns negative results and her blood alcohol level is determined to be 0. What is the most likely cause of her current symptoms? 1. Alcoholism 2. Scorpion sting 3. Biliary tract obstruction 4. Hypertriglyceridemia 5. Hypercalcemia

Antimitochondrial antibodies This patient's presentation is consistent with primary biliary cirrhosis. Elevated antimitochondrial antibodies may also be found in this disease.

A 42-year-old female presents with yellowing of the skin. She also reports that her urine has been darker than normal and her stools have been lighter than normal. Vital signs are stable. Physical examination reveals hepatosplenomegaly. Initial labs are notable for increased conjugated bilirubin, increased cholesterol, and increased alkaline phosphatase. If this patient's symptoms are due to an autoimmune reaction leading to lymphocytic infitration of and granulmonatous proliferation along the biliary track, which of the following additional labs would likely be positive? 1. Antimitochondrial antibodies 2. Antiendomysial antibodies 3. Anti-Jo-1 antibodies 4. Antihistone antibodies 5. Anticentromere antibodies

Abdominal ultrasound; Antibiotics and laparoscopic cholecystectomy within 72 hours This patient presents with acute cholecystitis. The most useful imaging study to confirm the diagnosis is a right upper quadrant ultrasound. Treatment includes cholecystectomy within 72 hours. This patient has multiple risk factors for acute cholecystitis. She is female, in her forties, and has a history of biliary colic. Recall the F's of gallbladder disease: fair, fat, forty, fertile, and female. Ultrasound should be the first imaging modality used when suspecting cholecystitis.

A 43-year-old woman presents with right upper quadrant pain. She has always had intermittent pain in the same area after certain meals, but her symptoms have never been this persistent before. Vital signs are temperature 38.2 degrees Celcius, heart rate 97, blood pressure 137/84, respiratory rate 14, and oxygen saturation 99% on room air. Body mass index is 29.1. Physical examination reveals tenderness to palpation of the right upper quadrant, worsened when the patient is asked to take a deep breath. To confirm the diagnosis in this patient, what is the recommended imaging study, and what would be the allopathic treatment? 1. CT abdomen with oral and IV contrast; Antibiotics and laparoscopic cholecystectomy within 24 hours 2. CT abdomen with IV contrast only; Antibiotics and laparoscopic cholecystectomy within 36 hours 3. PET scan; Antibiotics and laproscopic cholecystectomy within 36 hours 4. Abdominal ultrasound; Antibiotics and laparoscopic cholecystectomy within 72 hours 5. Abdominal X-ray; Antibiotics and laparoscopic cholecystectomy within 72 hours

Ultrasonography In this patient with a conjugated hyperbilirubinemia and elevated alkaline phosphatase, a right upper quadrant ultrasound is the diagnostic modality of choice in distinguishing between intra- and extrahepatic biliary obstruction. This woman's symptoms and laboratory results are consistent with biliary obstruction. Next, a right upper quadrant ultrasound is used to determine where this obstruction may lie. Ultrasound can be diagnostic for one of the major extrahepatic causes of obstruction: choledocholithiasis. This woman's history of scleroderma raises concern for the possibility of primary biliary cirrhosis (PBC), an intrahepatic cause of biliary obstruction that typically presents in middle-aged women. Fatigue and pruritus are common initial complaints, while jaundice is usually a later finding.

A 47-year-old woman with scleroderma is referred to the emergency department by her primary care physician. She had presented to him earlier that morning complaining of 2 weeks of fatigue and smelly, fatty bowel movements, as well as yellowing of her skin. She also notes intermittent abdominal cramping that worsens with meals. Preliminary labs reveal a total bilirubin of 4.2 mg/dL, direct 3.8 mg/dL and indirect 0.4 mg/dL. The alkaline phosphatase is elevated at 280 IU/L. She tells you she read about a liver disease that may be related to her scleroderma. Which of the following is the best initial method to address this woman's concern? 1. Serologic tests for presence of autoantibody 2. Ultrasonography 3. Blood smear 4. Computed tomography 5. Biopsy

IV fluid hydration, analgesics, NPO, Laparoscopic cholecystectomy This patients presents with acute calculous cholecystitis

A 48-year-old female presents to the emergency department with fevers, and worsening abdominal pain for 24 hours. Exam demonstrates an overweight female in distress. Abdominal exam is notable for tenderness to palpation in the right upper quadrant and a positive ultrasonic (US) murphy's sign. Vital signs are as follows: T 102.1 F HR 84 BP 135/92 RR 14 O2 Sat 97%. Lab studies demonstrate leukocytosis. What's the next best step in allopathic management? 1. IV fluid hydration, analgesics, NPO, Interval cholecystectomy after 7 days antibiotic therapy 2. IV fluid hydration, analgesics, NPO, Open cholecystectomy 3. IV fluid hydration, analgesics, NPO, Laparoscopic cholecystectomy 4. IV fluid hydration, analgesics, NPO, Hida Scan 5. IV fluid hydration, analgesics, NPO, Endoscopic retrograde cholangiopancreatography (ERCP)

IV fluids and analgesics The patient in the question stem has acute pancreatitis. The appropriate allopathic initial treatment is IV fluids, analgesics, and antiemetics

A 48-year-old man with a history of alcoholism presents to the emergency department with nausea, vomiting, and severe abdominal pain radiating to the back. He says his symptoms began 5 hours ago. A CT is obtained. What is the most appropriate initial allopathic treatment in this patient? 1. Gastrografin swallow study 2. Surgical intervention 3. IV fluids and analgesics 4. IV antibiotics 5. Upper endoscopy

CT scan of the abdomen Painless jaundice in an older individual should raise suspicion for malignancy. CT scan of the abdomen is indicated to evaluate for pancreatic cancer. Pancreatic cancer carries a poor prognosis and should be diagnosed as early as possible. Common symptoms are jaundice, scleral icterus, weight loss, and abdominal pain, although patients are often asymptomatic. Labs consistent with obstructive jaundice include elevated total and direct bilirubin.

A 56-year-old man presents to his primary care physician at the urging of his wife, who states he "looks yellow." The patient states he has no complaints and denies abdominal pain. Upon questioning, he recalls he may have had some weight loss over the past several months but cannot quantify the amount. His past medical history is significant for type 2 diabetes mellitus. Vital signs are within normal limits, and physical exam reveals mild jaundice. Blood work demonstrates a total bilirubin of 15 mg/dL (normal 0-1.5 mg/dL), direct bilirubin of 10 mg/dL (normal 0-0.3 mg/dL), and alkaline phosphatase (ALP) of 560 IU/L (normal 39-117 IU/L). Ultrasonography does not demonstrate biliary stones. Of the following, which is the next best step? 1. MRI scan of the abdomen 2. HIDA scan 3. ERCP 4. CT scan of the abdomen 5. Serologies

Elevated lipase This patient is suffering from an episode of acute pancreatitis. Serum lipase is the most widely available, sensitive, and specific test for the diagnosis of acute pancreatitis.

A 56-year-old man with a history of chronic alcoholism presents to the emergency room with 10/10 acute epigastric pain radiating to his back. He states that 1 day prior he drank what he considers a large quantity of alcohol, and since then, has had worsening abdominal pain, nausea, and lack of appetite. On physical exam he is hemodynamically stable, has a negative Murphy sign, and his abdomen is soft and nontender without palpable masses. A CT scan is ordered (Figure A). Which laboratory abnormality is most likely present in this patient? 1. Elevated lipase 2. Decreased lipase 3. Elevated AST and ALT 4. Decreased Ferritin 5. Increased ESR but decreased CRP

Alcohol use The patient in the above vignette is experiencing chronic pancreatitis. Alcoholism is a major risk factor for chronic pancreatitis. Chronic pancreatitis is often caused by obstruction and dysfunction of the pancreatic system. It is classically associated with alcoholism and it follows a persistent and recurrent disease course. Symptoms of chronic pancreatitis include persistent epigastric pain, constipation, flatulance, and steatorrhea (because of decreased lipase). Laboratory evaluation shows elevated amylase and lipase. Allopathic reatment includes alcohol cessation, oral pancreatic enzymes, and pancreatectomy in severe cases.

A 59-year-old female presents to the ER with persistent epigastric pain. She states that she has had multiple episodes of pale, voluminous, foul-smelling stools that seem to float and that are difficult to flush. Her labs are remarkable for an elevated amylase and lipase. Abdominal radiographs show a mild ileus. What in her past medical history is most likely to have contributed to her pathology? 1. Tobacco use 2. Alcohol use 3. Illicit drug use 4. Prior abdominal surgery 5. Prior intestinal parasites

CA 19-9 is a marker for this disease. Pancreatic cancer can present with dull abdominal pain (although can be painless), weight loss, jaundice, and anorexia. Carbohydrate antigen 19-9 (CA 19-9) is positive in over 80% of tumors.

A 69-year-old male presents to clinic with malaise. He has no past medical history and states that he has been "the picture of health his entire life." He reports that he has not felt quite himself for the past several months during which he has had weight loss, dull abdominal pain, and decreased appetite. The following is noted on examination of his eyes . Which of the following is true regarding this patient's disease? 1. Patients often present with rapid development of glucose intolerance and severe diabetes. 2. The majority of cases are in the body of the organ. 3. The disease is most common in caucasians. 4. Caffeine consumption is an established risk factor. 5. CA 19-9 is a marker for this disease.

Acute cholecystitis This patient is presenting with acute acalculous cholecystitis. Acute acalculous cholecystitis is the acute inflammation of the gallbladder in the absence of gallstones, often observed in very ill patients with sepsis, trauma, or severe burns.

A 70-year-old male presents to the emergency department with fever and productive cough that has progressed rapidly over the past day. On exam, he is very ill appearing and his vitals demonstrate T: 39 deg C, HR: 95 bpm, BP: 80/40 mmHg, RR: 15, SaO2: 93%. A CBC is obtained which demonstrates a white blood cell count (WBC) of 14,000. The patient is subsequently diagnosed with severe sepsis secondary to pneumonia and is transferred to the ICU after intubation, appropriate antibiotic therapy, and resuscitation measures are initiated. The patient improves steadily over the subsequent days in the ICU with improving vitals and decreasing WBC. However, on hospital day 4 he develops a fever to 41 deg C, and his WBC elevates to 16,000. On exam, he appears to withdraw in pain when his abdomen is palpated. Liver function tests and amylase/lipase are ordered and shown to be within normal limits. What is the most likely cause of this patient's current presentation? 1. Cholelithiasis 2. Cholangitis 3. Acute cholecystitis 4. Acute pancreatitis

Primary Biliary Cirrhosis (PBC)

A Pt presents with a gradual onset of *Pruritus, jaundice, and fatigue*, the pruritis < night, < wool or heat and reports light colored stool. On PE you find HSM, vague RUQ discomfort, and skin xanthomas/xanthelasmas. What is your most likely dx?

Acute Pancreatitis Fever, Cullen's or Grey Turner sign: *ER referral*

A pt presents with *Severe epigastric radiating to middle of back* (50%) or left scapula Radiating pain described as *constant, 'boring'* and steady pain *< lying on back*, coughing, breathing deeply, *> sitting up or bending forward* *< alcohol or fatty meals* *Pain appears suddenly, worsens rapidly* (gallstone etiology) *Nausea/Vomiting* (90%), persists for hours Anorexia Patient is visibly distressed, writhing from pain Tachycardia, hypotension Great tenderness to palpation of epigastrum What do you suspect? What would you do if they presented with a fever, periumbilical or flank bruising?

Cholecystitis Fever: Refer to ER!!

A pt presents with *sharp, sudden RUQ pain* for *>6 hrs* that radiates to right upper shoulder or scapula. *Pain < fatty foods*, often ingested in recent history, n/v, and diaphoresis. Tachycardia - from pain, Patient lies still on table (*< movement*) *Murphy's sign positive*, Rebound tenderness/guarding, *Boas's sign* (hyperesthesia underneath right scapula). *Courvoisier Sign* (palpable GB on examination). What do you suspect. What would you do if they had a fever?

Chronic Pancreatitis

A pt presents with *waxing/waning course of post-prandial upper abdominal/epigastric pain, often radiating to the back* (episodes lasting 15-30 mins), vague sx such as dyspepsia, weight loss, anorexia, n/v, pancreatic insufficiency (*fatty stools*), PE reveals vague upper abdomen tenderness and discomfort. They report this has been occurring >6 months. What is your most likely dx?

48-year-old mother of 3 with a history of right upper quadrant pain following fatty meals This patient's presentation is consistent with biliary colic. Abdominal ultrasonography is the best initial method for evaluating gallbladder pathology.

For which of the following patients is an abdominal ultrasound the most appropriate first diagnostic test? 1. 69-year-old female smoker with 10 pound weight loss and change in sputum 2. 64-year-old male with known prostate cancer presenting with lower extremity weakness and loss of bladder control 3. 58-year-old male with Marfan syndrome presenting with acute onset chest pain radiating to the back 4. 28-year-old female with Crohn's disease presenting with 5 hours of abdominal pain, constipation, and nausea 5. 48-year-old mother of 3 with a history of right upper quadrant pain following fatty meals

Exercise, meal counseling (*High Protein, low carbohydrate diet*), sleep counseling, remove environmental toxins, address stress *antioxidants (ALA*, NAC, glutathione, SAMe, CoQ10, Green tea, lecithin, taurine, glycine, phosphatidylcholine, *vitamin E*, *betaine* (reduces steatosis) Botanicals inflammation-modulating (curcuma/turmeric), immunomodulator (astragalus, gynestemma), insulin-sensitizers (momordica cahrantia (bitter melon), cinnamomum, panax ginseng, hepatoprotectives (silybum, camellia sinensis) acu (UB 23, Ren4, Ki3, Sp6) Homeo (phos, lyco, merc)

How would you tx NAFLD?

Address diet (add broths, fermented foods, avoid food irritants (*coffee, spice, black tea, soda, fatty food*) *Avoid alcohol up to 6 months*, consider discontinuing all together, EVEN herbal tinctures Botanicals: Robert's Formula, Anti-inflammatory/immune modulators *Antioxidants* *Pancreatic enzyme without HCl* Hydrotherapy Homeopathy

How would you tx acute pancreatitis?

Cholagogues: Fumaria, Taraxacum, Chianothus, Berberis, Cynara, Chelidonium Phosphatidylcholine 1000-4000 mg QD Lecithin: 1 TBSP QD (~7-8 gm) (Watch soy allergy/sensitivity!) Glycine, Taurine, Methionine Diet: high EFA and veggies, low animal protein Regular exercise Gall bladder flush (MAXIMUM to do this is TWICE a year, every 6 months, NOT MORE FREQUENTLY)

How would you tx biliary sludge?

NPO, *fluids ok*. FAST until system settles down Diet: in general *avoid eggs, onions, pork* Light meals: soups, fluids, oatmeal, steamed veggies No oil, sauces, heavy foods (meats) Castor oil packs over liver/abdomen Spasmolytic, inflammation-modulating herbs, immune stimulant herbs *Ox bile + lipase post-cholecystectomy, for life!* Robert's Formula Biovegetarian: 2 caps QID Liver product with herbs, cholagogues, taurine/glycine Curcuma Carotenoids Homeopathy (*Chelidonium*: RUQ pain radiating to right scapula, < 4 am, 2 pm or 4 pm, eating > *Lycopodium*: RUQ pain radiating to back, < eating Mag mur, Puls, others) Watch them carefully. If they don't respond soon or worsen, refer to ER Can take 1-3 days, like pancreatits DO FOOD ALLERGY TEST

How would you tx cholecystitis?

*Diet: vegan* diet - most common exacerbating food are *eggs, pork, onions*. *Bitter veggies* *Avoid food allergies* Castor Oil packs QD 3-5 x week - anti-inflammatory Daily aerobic exercise with slow, steady weight loss *Phosphatidylcholine*: 1-2 g TID Fish Oils: 6 g QD Peppermint, enteric coated: 1-2 cap TID Rowachol: terpenoids with mehta, pinene, menthone, borneol, camphene, cineol in olive oil base. 100 mg 1-2 bid dissolved gallstones *Lecithin*: 1 TBS QD Ox Bile can help the GB rest as it heals Botanicals (*Spasmolytic*: mentha, piper, dioscorea, viburnum, angelica archangelica. *Cholagogue/cholaretics*: taraxacum, chianothus, berberis, cynara, chelidonium Magnesium (IV or PO) Atropa belladonna (low dose) D-Limonene *Antioxidants*: Vit C, carotenoids *Lipotropic factors* Choline, methionine, inositol Regular BM's Acupuncture: Jin shi san, Yang gan li dan Homeopathy (Berberis, Belladonna, China, Lycopodium) For acute attacks: "42's"

How would you tx cholelithiasis?

Serum *Lipase* (*best for diagnosis*) Serum *Amylase* (> 3x normal is diagnostic) *Trypsinogen Activation Peptide* (TAP) *CBC with differential*: WBC's 12,000-20,000 with neutrophil shift *CMP*: may show elevated glucose, BUN, creatinine, electrolytes (abnormal) *Lipid panel* *CRP > 150* mg/dL at 48 hours is associated with severe pancreatitis *Procalcitonin* - (high) necrosis Imaging: RUQ Abdominal U/S (easy, benign, quick) Abdominal MRI Both are best suited to examine for obstruction *Abdominal CT with contrast - most reliable* *Referral to ED for surgical evaluation!*

If you suspect acute pancreatitis, what labs/imaging would you order?

Labs CBC (leukocytosis in acute) CMP (ALP mildly elevated) ALT/AST Bilirubin (mild elevation) Amylase, Lipase Imaging US, or CT

If you suspect cholecystitis, what labs/imaging would you order?

*Cigarette smoking* (well-established) #1! *Western lifestyle* (obesity, physical inactivity) Migrant Japanese to US have higher rate of pancreatic cancer than those living in Japan African American, Chinese living in US also affected higher than Caucasian BRCA1, BRCA2, Lynch Syndrome, etc. Hereditary pancreatitis Older age

What are risk factors for pancreatic cancer?

jaundice, dark urine or clay colored stools

What are s/sx of Hyperbilirubinemia?

Alanine transaminase (ALT) Normal: 10-40 U/L

What LFT is More specific than AST for liver damage? What is the normal value?

Alkaline phosphatase Normal 30 -120 U/L

What LFT is elevated in *large bile duct obstruction*, intrahepatic cholestasis or infiltrative diseases of the liver (Also elevated in certain bone diseases, 3rd trimester pregnancy )? What is the normal value?

Aspartate transaminase (AST or SGOT) Normal: 6-40 U/L

What LFT is tests an Important enzyme in amino acid metabolism? What is the normal value?

GGT (Gamma Glutamyl Transpeptidase) Normal Adult Range: 0 - 42 U/L

What LFT is the most sensitive marker for cholestatic damage and is increased in chronic alcohol toxicity? What is the normal value?

General HEENT: Pallor, diaphoresis, level of distress, *fetor hepaticus*, *Kayser-Fleischer* ring, scleral icterus CV: Rate, rhythm, rubs, heart sounds Chest: Wheezing, crackles, breath sounds, *gynecomastia*(alcohol) Abd: Inspect : *Distention*, scars, masses Palpate: *organomegaly* Percuss: Tympany Fluid wave for evidence of ascites Abdominal wall vascular collaterals (caput medusa) Rectal: Masses, gross blood or melena, heme (+) stool, hemorrhoids Extremities: Nail changes: *Muehrcke's nails* — paired horizontal white bands separated by normal color *Terry's nails* — proximal 2/3 of nail plate appears white, whereas the distal one third is red *Asterixis* (encephalopathy) *Vascular spiders* (spider telangiectasia, spider angiomata) *Palmar erythema* (cirrhosis) *Dupuytren's contracture*: Flexed contraction (cirrhosis)

What PE findings would you expect in liver pathologies?

Pain management Cessation of alcohol, smoking Small meals, hydration Surgery

What are allopathic tx options for chronic pancreatitis?

NSAIDs/Aspirin Opioids Bile Acids (UDCA) 10 mg/kg/day Cholecystectomy by laparoscopy - go-to option (Short-term solution. *1/3 develop chronic diarrhea*) Lithotripsy - sonic shock wave Stone dissolution with drugs

What are allopathic tx options for gallstones?

Gangrene Perforation Empyema Sepsis

What are complications of Cholecystitis?

Cholecystitis, cholangitis, choledocholithiasis PUD Pancreatitis (acute or chronic) Gastritis (acute) GERD AAA Appendicitis Diverticulitis (small majority present with LLQ) Angina/MI IBS Hepatitis (acute) Abdominal abscess Esophageal spasm, esophagitis IBS (diarrhea from bile dumping) Biliary dyskinesia, sphincter of Oddi dysfunction

What are differentials for Cholelithiasis?

AST, ALT, GGT, Alk Phos Measure of damage to liver parenchyma

What are liver function tests?

Central obesity Insulin resistance DM II Dyslipidemia, especially elevated TG's Soda, high fat and simple sugar intake M:F equivocal, most diagnosis in 40's-50's Hispanic, African-American population Cholecystectomy? Metabolic Syndrome Other: PCOS, hypothyroid, sleep apnea Drugs: Valproic acid, steroids, Tamoxifen, estrogen, Methotrexate ENVM factors: solvents, TPN, weight reduction surgery, rapid wt loss/starvation, celiac, protein/energy malnutrition, choline deficiency

What are risk factors for NAFLD?

Pregnancy Rapid weight loss Critical illness involving low or absent oral intake or TPN Post-gastric surgery Biliary stones with common bile duct obstruction Drugs such as Ceftriaxone

What are risk factors for biliary sludge?

Pain is located in epigastrum or RUQ Recurrent, but occurs at variable intervals (not daily) Lasts at least 30 minutes, with pain-free intervals Builds up to a steady level Severe enough to interrupt daily activities or lead to an ER visit Is not relieved by BM's, postural changes, or antacids GB should be present and all liver, pancreatic enzymes, bilirubin are *normal*

What are the Rome III criteria for Functional GB Disorder?

Mild jaundice Fatty stools Chills, fever, clammy skin, sweating Weakness, weight loss Tachypnea/tachycardia Hypotension Absent bowel sounds Muscle spasms (hypocalcemia) Grey Turner/Cullen's sign +

What are the alarm signs in acute pancreatitis?

*Hemolytic* (congenital, Acquired) *Obstructive*

What are the causes of jaundice?

Disrupts gut flora leading to SIBO

What are the concerns with alcoholic liver disease (ALD)and the small intestine?

Excessive stimulation of macrophages and lymphocytes Kupffer cells in liver react to higher levels of lipopolysaccharides from gut

What are the concerns with alcoholic liver disease and immunologic mechanisms?

*5 "F"s*: female, fair, forty, fertile, fat (flatulent) Increased estrogens: OCP, pregnancy, HRT Rapid weight loss/low caloric intake (or fasting) FHx Native Americans, Hispanic, European Caucasian Obesity/Western Diet (high fat) Digestive disturbances - food sensitivities particularly *EGGS, ONIONS, PORK* PPI usage, low stomach acid

What are the risk factors for Cholelithiasis?

Alcoholism Poor diet (low antioxidant status) Hypertriglyceridemia (> 1000) *Cholelithiasis* (45%) - More prevalent in females *Alcoholism* (35%) - More prevalence in men Snake and Scorpion bites

What are the risk factors for acute pancreatitis?

Metabolic liver disease Chronic Hep

What are the top two causes of elevated AST?

Cirrhosis NAFLD Viral Hepatitides Autoimmune hepatitis

What are your differentials for ALD?

*Alcoholism must be ruled out!* Viral Hepatitis Celiac disease Wilson's Disease Biliary disease Autoimmune GI disease: hepatitis, celiac, Crohn's, UC, etc. Hemochromatosis

What are your differentials for NAFLD?

PUD, perforated ulcer Acute cholecystitis Cholangitis, cholelithiasis Biliary colic, cholecystectomy Intestinal obstruction (LI/SI) Peritonitis MI Dissecting AA Pneumonia

What are your differentials for acute pancreatitis?

Metastasis Other local organ tumors Cholangitis

What are your differentials for biliary cancer?

Acute biliary colic (biliary dyskinesia) Pancreatitis Perforated peptic ulcer Diverticulitis Pyelonephritis Appendicitis

What are your differentials for cholecystitis?

Deficiencies in bilirubin metabolism (i.e cirrhosis or viral hepatitis)

What causes a hepatic rise in bilirubin?

Deficiencies in bilirubin excretion Elevation of direct (conjugated BR) (i.e obstruction of bile duct)

What causes a post-hepatic rise in bilirubin?

Increased bilirubin production (i.e hemolysis)

What causes a pre-hepatic rise in bilirubin?

Only radiolucent stones show up on x-ray Radiolucent stones are cholesterol, Radio-opaque are pigment stones

What gallstones show up on x-ray and which ones don't?

ERCP

What imaging can diagnose and remove gallstones at the same time?

Abdominal U/S

What imaging would you order if you suspected biliary sludge?

Presence of *hepatic steatosis*; the most common cause of *elevated liver enzymes* when *no other causes* for secondary *hepatic fat* accumulation are present

What is NAFLD?

Excess estrogen

What is associated with women who develop acute pancreatitis?

Mixture of precipitated solids from bile (Components typically cholesterol crystals, bile salts, calcium pigment, mucin)

What is biliary sludge?

*Motility disorder*: lack of motility or uncoordinated motility of gallbladder or Sphincter of Oddi Biliary-type pain, *no evidence of gallstones or inflammation* (acalculous cholecystopathy)

What is functional gallbladder disorder?

Based on Risk Classification and Predictors *ERCP with removal of stones* The ducts are worked upon with electrocautery to allow stones to drop into the duodenum Cholecystectomy (can be elective)

What is the allopathic tx for Choledocholithiasis?

*Antibiotics*? Remove the cause/medication Controversial - can cause systemic fungal infections with high mortality rates. *DO NOT GIVE* in general, can aggravate (Only in septic shock, cholangitis, abscess) Pain management (Demerol) IV fluids Surgery Indicated when obstructive lesion is present - ERCP Discharged 24-48 hours to FU with PCP or Gastro (Acute without complication: WATCH AND WAIT. 80% respond to conservative care)

What is the allopathic tx for acute pancreatitis?

If asx, no treatment necessary Cholecystectomy

What is the allopathic tx for biliary sludge?

Elevated serum AMA, serum transaminase and ALP Evidence of small bile duct destruction/scarring from cirrhosis on liver biopsy

What is the diagnostic criteria for PBC?

Most gallstones are composed of *cholesterol* Others composed of bilirubin = pigment stones

What is the most common type of gallstone?

Poor due to late diagnosis Medial survival rate < 5%

What is the prognosis for pancreatic cancer?

LDH (Lactic Acid Dehydrogenase) Normal Adult Range: 45 - 90 U/L

What lab value indicates liver damage, cellular death and/or leakage from the cell with cancer or ischemic injury? What is the normal range?

Albumin Normal 3.5 to 5.3 g/dL

What lab value is Decreased in *chronic liver disease*, nephrotic syndrome? What is the normal value?

Labs *CA 19-9* CBC/CMP Imaging *Abdominal CT w/contrast*

What labs/imaging do you order if you suspect pancreatic cancer?

Serum amylase/lipase: often normal *Fecal Elastase-1* (or serum) - indicates pancreatic enzyme insufficiency Secretin-stimulation test - NG tube, given secretin and measure pancreatic output of enzymes as a result Imaging Plain film x-ray to assess for calcification (30%) Abdominal US/CT *MCRP diagnostic test of choice* - most sensitive

What labs/imaging would you order if you suspect chronic pancreatitis?

bilirubin levels exceed *3-4 mg/dl*

What level of bilirubin will jaundice be noticed?

Total Protein and serum albumin Total Bilirubin Prothrombin Time (PT / INR)

What measures actual liver "synthetic function"?

evaluated for other causes of abdominal pain

What would you do for a pt that does not *NOT fulfill ALL of the criteria* for functional GB disorder?

Acute viral hepatitis Acetaminophen toxicity/overdose Shock liver

What would you expect if AST and ALT >1000?

Cholestasis and/or obstruction

What would you expect with labs that show Elevation ALP and Bilirubin?

Cellular injury

What would you expect with labs that show Elevation AST and ALT only?

evaluate blockage in the biliary ducts If the dye isn't visible, indicates a blockage

When we do a HIDA scan, what are we looking for in terms of gallbladder functioning?

during acute cholecystitis and acute biliary colic Risk of causing acute crisis due to excess GB contraction

When would a gallbladder flush be contraindicated? Why?

Labs CMP - ALT/AST Increased bilirubin, elevated Alk Phos CBC Pancreatic enzymes Imaging US 1st, then based on findings ERCP or MRCP/EUS

You suspect Choledocholithiasis. What labs/imaging would you order?

*Alk Phos (ALP) - highest* Bilirubin ALT/AST, GGT Lipid panel *ANA - anti-centromere pattern, AMA titers* (95%) Imaging: ERCP Also US, liver biopsy, IV cholangiography

You suspect PBC, what labs/imaging will you order?

same as cholelithiasis PLUS ERCP *HIDA scan*: *CCK + cholescintigraphy to measure GBEF* GBEF < 40%

You suspect a pt has functional GB disorder, what labs/imaging would you order?