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
      

HIV with Hepatobiliary complication

· A history of mild jaundice and constitutional symptoms (eg, fatigue, nausea), is more consistent with intrahepatic disease, such as acute viral hepatitis (eg, hepatitis A, hepatitis B, or hepatitis C infections)

· The subacute onset of fevers, chills, anorexia, and weight loss in a patient with advanced AIDS and hepatosplenomegaly may be related to disseminated infections, such as MAC, tuberculosis, Bartonella henselae, visceral leishmaniasis, histoplasmosis, or lymphoma. (See appropriate individual topics).

· In contrast, signs of jaundice accompanied by relatively acute abdominal pain suggest extrahepatic disease, such as a solid tumor or lymphadenopathy at the porta hepatis.

· Right upper quadrant pain with or without jaundice may be a presenting complaint in AIDS-related cholangiopathy, papillary stenosis, acalculous cholecystitis, cholelithiasis/choledocholithiasis, or drug-induced liver injury.

· A history of abdominal bloating, nausea, weight loss and right upper quadrant pain may be associated with the lactic acidosis syndrome, which is more common in women than men and usually secondary to chronic nucleoside analogue use with didanosine and/or stavudine. These agents are no longer recommended in the United States and Europe, but are commonly used in resource-limited settings. (See "Mitochondrial toxicity of HIV nucleoside reverse transcriptase inhibitors" and "Adverse effects of antiretroviral therapy in developing countries".)

Neurological complication of Alcoholism

 

1. Acute alcoholic intoxication: mild euphoria to coma (depends on the serum alcohol level).

2. Alcoholic blackout: transient amnesia after a binge.

3. Alcohol withdrawal syndromes: tremulousness, autonomic hyperactivity, hallucinosis.

4. Alcohol withdrawal seizures.

5. Delirium tremens: confusion, florid hallucination, and autonomic hyperactivity.

6. Nutritional deficiencies:

• Wernicke-Korsakoff syndrome.
  
• Alcoholic polyneuropathy (Gradual onset,More sensory,Painful paresthesia)
  
• Pellagra.
  

7. Neurological complication of uncertain etiology:

• Alcoholic cerebellar degeneration.

• Central pontine myelinolysis.

• Marchiafava-Bignami disease: degeneration of corpus callosum.

• Alcoholic myopathy.

• Alcoholic amblyopia.

8. Encephalopathy:

• Hepatic encephalopathy.

9. Traumatic

• Subdural hematoma
  
• Post traumatic epilepsy
  

10.Other

• Stroke
  
• Movement disorder
  

 

 

• HIV-related causes of esophageal disease

• Fungal disease
• Candida species
• Ulcerative disease
• Idiopathic(HIV esophagitis)
• CMV
• Herpes simplex
• Pill-induced
• Neoplastic disease
• Kaposi's sarcoma
• Non-Hodgkin's lymphoma

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