Cholecystitis and Cholelithiasis Overview

Most commonly caused by cystic duct blockage due to gallstones.
Symptoms include fever and right upper quadrant (RUQ) pain lasting a few hours.
RUQ tenderness on examination; positive Murphy's sign indicated by cessation of inspiration during palpation.
Liver function tests (LFTs) typically normal.
Ultrasound reveals thickening of the gallbladder.
Next step in management: Ultrasound.
Most accurate diagnostic test: HIDA scan.
Initial treatment: NPO (nothing by mouth), IV hydration, and analgesic (Ketorolac).
Second-line treatment: Laparoscopic cholecystectomy.

Most common stone type: mixed cholesterol stones.
Black-pigmented stones linked to hemolytic disease.
Brown-pigmented stones often associated with infection.
Acute cholecystitis is a common complication.
Cholelithiasis: typically asymptomatic, normal LFTs.
Choledocholithiasis: symptomatic, elevated LFTs, and ultrasound shows biliary duct dilation.
Best initial test for both conditions: Ultrasound.
Most accurate test for choledocholithiasis: Endoscopic ultrasound (EUS).
Treatment of choice for choledocholithiasis: ERCP (endoscopic retrograde cholangiopancreatography).
Second-line treatment for asymptomatic cholelithiasis: observation; for symptomatic: cholecystectomy.
Choledocholithiasis management: ERCP stone removal followed by cholecystectomy.

Most often caused by choledocholithiasis.
Common pathogens include E. coli and Klebsiella.
Classic presentation: RUQ pain, fever, jaundice; may include altered mental status and shock.
LFTs elevated.
Priority: stabilize the patient if unstable.
Best initial test: Ultrasound; if negative, proceed to MRCP; if positive, do ERCP.
Most accurate test: MRCP.
Treatment of choice: IV antibiotics, IV fluids, analgesia, and biliary drainage via ERCP.
Second-line treatment: Cholecystectomy after resolution of acute cholangitis for patients with choledocholithiasis.

Diverticulitis noted in older patients (60s) with acute fever and left lower quadrant pain.
Diverticulosis typically asymptomatic, may cause left lower quadrant pain with painless hematochezia, but no fever.
Best initial test for diverticulosis: Colonoscopy; for diverticulitis: CT scan.
Most accurate test for both: Colonoscopy for diverticulosis, CT scan for diverticulitis.
Treatment of choice for diverticulosis: increase fiber and hydration.
Diverticulitis treated with ciprofloxacin plus metronidazole, or alternatives like trimethoprim-sulfamethoxazole plus metronidazole, Augmentin, or moxifloxacin.
Second-line treatment: Surgery if symptoms persist, recur, or complications arise.

Common symptoms include abdominal pain, hematochezia, fever, and weight loss.
Crohn's Disease: skip lesions, transmural lesions, ASCA positive, may involve perianal region.
Ulcerative Colitis: continuous lesions limited to colon, mucosal surface affected, pANCA positive, no perianal involvement.
Most accurate test for IBD: Colonoscopy and biopsy.
Treatment of choice for Crohn's: Steroids for flares, Budesonide for remission, Mesalamine or sulfasalazine for maintenance.
Ulcerative Colitis treatment: Steroids for flares, topical mesalamine for remission, maintenance with topical mesalamine or sulfasalazine.
Second-line treatment for refractory or moderate/severe disease includes anti-TNF medications (Infliximab, Adalimumab) and possibly Azathioprine.
Surgery may be curative for Ulcerative Colitis but not for Crohn's.

Most common cause of recurrent abdominal pain in the U.S., more prevalent in women.
Symptoms: abdominal pain improved with defecation, alternating constipation and diarrhea, normal labs and imaging.
Next best step: Rule out other causes of abdominal pain.
Treatment of choice includes adequate hydration, dietary fiber, and antispasmodic medications (hyoscyamine or dicyclomine).
For constipation-predominant IBS, osmotic laxatives (Linaclotide, lubiprostone, plecanatide) can be effective.