Symptoms & Signs
of Acute Cholecystitis

Symptoms

• 75% have prior history of biliary colic
  
• RUQ
  pain
  >90%
  
• Fever 50%
  

Signs

• Fever 50%: may
  be absent in elderly,
  gangrenous
  cholecystitis or empyema GB
  
• Jaundice 20% : mild
  jaundice
  
• RUQ
  tenderness
  
• Murphy's
  sign: S 65%, Sp 87%*
  

 

Investigations in Acute Cholecystitis

• CBC : no leukocytosis in 1/3 of patient,
  esp
  in
  elderly and gangrenous cholecystitis
  
• LFT : hyperbilirubinemia in 20% (TB
  <6 mg/dl),
  AP usually normal
  
• Ultrasonography : sensitivity 88%, specificity 80% from meta-analysis
  
  • Gallstones
    
  • Thickening
    GB wall
    > 4 mm
    
  • Edema
    of GB ('double wall sign')
    
  • Pericholecystic
    fluid
    
  • Sonographic
    Murphy's sign (PPV 90%, NPV 90%)
    

 

 

 

 

 

 

 

Indicated

• Porcelain GB
  
• Travel to remote area
  
• During await for organ Tx
  
• During wt. loss surgery
  
• Sickle cell anemia
  
• Young Amerindian (GBCa 20x)
  
• GS in children
  

 

 

 

Controversial

• GS >3 cm (GBCa 9x)
  

Not indicated

• DM
  
• Thalassemia
  
• Dyspepsia
  

Advice

MR&AR

Acute Cholecystitis

Symptoms & Signs
of Acute Cholecystitis

Symptoms

§  75% have prior history of biliary colic

§  RUQ pain >90%

§  Fever 50%

Signs

§  Fever 50%: may be absent in elderly, gangrenous cholecystitis or empyema GB

§  Jaundice 20% : mild jaundice

§  RUQ tenderness

§  Murphy’s sign: S 65%, Sp 87%*

Investigations in Acute Cholecystitis

§  CBC : no leukocytosis in 1/3 of patient, esp in elderly and gangrenous cholecystitis

§  LFT : hyperbilirubinemia in 20% (TB <6 mg/dl), AP usually normal

§  Ultrasonography : sensitivity 88%, specificity 80% from meta-analysis

§  Gallstones

§  Thickening GB wall > 4 mm

§  Edema of GB (‘double wall sign’)

§  Pericholecystic fluid

§  Sonographic Murphy’s sign (PPV 90%, NPV 90%)

LC in Asymptomatic GS

Indicated

§  Porcelain GB

§  Travel to remote area

§  During await for organ Tx

§  During wt. loss surgery

§  Sickle cell anemia

§  Young Amerindian (GBCa 20x)

§  GS in children

Controversial

§  GS >3 cm (GBCa 9x)

Not indicated

§  DM

§  Thalassemia

§  Dyspepsia

Malabosoption

Acromegaly

• Vital signs: BP
  
  
• Weight,
  Height
  
  
• Typical face:
  
  
  • Frontal bossing
    
    
  • Prognathism
    
    
  • Macroglossia
    
    
  • Coarse
    faces
    
    
  • Thickening
    of the nose
    
    
• Cutis vertices gyrate
  
  
• Thyroid gland: enlarged,
  MNG
  
  
• Skin:
  skin
  tags, Oily skin, acanthosis
  nigrican
  
  
• Wide and spread
  hands.
  
  
• Carpal tunnel syndrome
  
  
• Heart: Cardiomegaly
  
  
• Abd: Hepatomegaly
  
  
• Nervous system:
  
  
  • VF
    
    
• Osteoarthritis
  
  
• Galactorrhea
  
  

 

IGF-1

• Screening test
  
  
• Higher than same age
  
  

• 75 g OGTT
  
  
  • GH
    > 1 ug/L
    
    
• Goal
  
  
  • GH
    < 1ug/L
    
    
  • Normalized IGF-1
    
• Modalities
  
  
  • Surgery
    
    
  • Radiation
    
    
  • Medication
    
    
    • Dopamine
      agonist
      
      
    • Somatostatin
      analog
      

Prolactinoma

• Galactorhea
  
  
• Amenorhea
  
  
• Infertile
  
  
• Mass
  

Approach

History

• drug
  use
  
  
• menstruation
  
  
• Pituitary
  function
  
  
• VF
  and VA
  
  
• Hypothyroidism
  
  
• CRF
  
  
• 
   

 

• Hypothalamic-pituitary disorder
  
  
  • Tumors: craniopharyngiomas, germinomas, pituitary micro-macroadenoma
    
  • Infiltrative diseases:
    sarcoidosis, tuberculosis, histiocytosis
    
    
  • Others: Empty sella, Pituitary stalk section
    
    
• Drugs:
  
  • Neuroleptics, Receptors blockers: metoclopramide, sulpiride, domperidone, cimetidine
    
    
  • Antidepressants:
    amoxapine, imipramine, amitriptiline,
    
  • Anti HT: alpha-metildopa, reserpine, CCB (verapamil)
    
    
  • Others: Estrogens, Opiates
    
    
• Primary hypothyroidism
  
  
• Kidney of liver failure
  
• Neurogenic: chest or spine lesions, breast and nipple stimulation
  
• Idiopathic
  
• Physiological conditions: pregnancy, lactation
  
  

 

Acromegaly

Acromegaly

• Vital signs: BP
  
  
• Weight,
  Height
  
  
• Typical face:
  
  
  • Frontal bossing
    
    
  • Prognathism
    
    
  • Macroglossia
    
    
  • Coarse
    faces
    
    
  • Thickening
    of the nose
    
    
• Cutis vertices gyrate
  
  
• Thyroid gland: enlarged,
  MNG
  
  
• Skin:
  skin
  tags, Oily skin, acanthosis
  nigrican
  
  
• Wide and spread
  hands.
  
  
• Carpal tunnel syndrome
  
  
• Heart: Cardiomegaly
  
  
• Abd: Hepatomegaly
  
  
• Nervous system:
  
  
  • VF
    
    
• Osteoarthritis
  
  
• Galactorrhea
  
  

 

IGF-1

• Screening test
  
  
• Higher than same age
  
  

• 75 g OGTT
  
  
  • GH
    > 1 ug/L
    
    
• Goal
  
  
  • GH
    < 1ug/L
    
    
  • Normalized IGF-1
    
• Modalities
  
  
  • Surgery
    
    
  • Radiation
    
    
  • Medication
    
    
    • Dopamine
      agonist
      
      
    • Somatostatin
      analog