Treatment of Gallstones in Adults Revised 2001

Treatment of Gallstones in Adults Revised 2001

RECOMMENDATION 1: Asymptomatic gallstones
Surgical consultation and surgery are not recommended for adults who have asymptomatic gallstones
found incidentally by diagnostic imaging or abdominal surgery.

RECCOMENDATION 2: Symptomatic gallstones
a) Surgical Intervention
If a patient with symptomatic gallstones puts a relatively high value on preventing recurrent pain
then surgical removal of the gallbladder may be considered. About 70 per cent of patients will
experience the recurrence of gallstone-related pain if left surgically untreated. Laparoscopic cholecystectomy
is recommended in symptomatic patients who are suitable candidates for surgery and
who wish to have surgical intervention.
b) Non-surgical Management
(i) Oral bile acids are rarely indicated for dissolution therapy in patients who are unsuitable for or
who decline surgery.
(ii) Lithotripsy is not indicated for the primary treatment of simple gallstone disease.

Most gallstones are asymptomatic and remain so for the life of the patient.Complications or symptoms
will develop in one to two per cent of patients per year. It also appears that the longer the stones remain
quiescent, the less likely are complications to appear. Surgery is not indicated in asymptomatic
patients.Some exceptions include patients with sickle cell disease and gallstones, and patients with
calcified (porcelain) gallbladders where the risk of gallbladder cancer is very high. Prophylactic
cholecystectomy had previously been recommended in diabetic patients in order to avoid the high morbidity and mortality rates associated with emergency operations. However, the increased risks are
due to cardiovascular disease and other comorbid conditions which are present whether the surgery
is elective or emergency. Therefore, asymptomatic patients with diabetes should not have
prophylactic surgery.
Laparoscopic cholecystectomy is now the standard approach to the treatment of symptomatic gallstones.

A 28-year-old woman with borderline personality disorder has been stable on fluoxetine and lithium carbonate for the past year and is adherent with psychotherapy. She now wishes to become pregnant. Which of the following actions by her psychiatrist is most appropriate?

a. Continue fluoxetine but discontinue lithium until after the first trimester.
b. Discontinue both lithium and fluoxetine.
c. Maintain both lithium and fluoxetine at current doses.
d. Review risks and benefits of possible treatment options with the patient.
e. Tell the patient that pregnancy is too risky at this point in her treatment.

D

Antidepressants, anticonvulsants, and short-term use of neuroleptics are common for BPD. Decisions about medication use should be made cooperatively between the individual and the psychiatrist. Issues to be considered include the person's willingness to take the medication as prescribed, and the possible benefits, risks, and side effects of the medication, particularly the risk of overdose.

A patient sees a psychiatrist for frequent shifts in mood and difficulties in interpersonal relationships. After a complete evaluation, a diagnosis of borderline
personality disorder is made and the psychiatrist discusses a plan of treatment with the patient. The psychiatrist recommends extended outpatient psychotherapy,but the patient is concerned about the costs of care. Which of the following responses by the psychiatrist is most appropriate?

a. If cost is an issue, meeting intermittently for therapy will be less expensive even if occasional hospitalizations are needed.
b. Surprisingly, this kind of therapy is cheaper than being seen for medication management alone.
c. There is good evidence that this kind of therapy is often effective for your disorder; briefer treatment may not work.
d. This kind of therapy is prohibitively expensive, but your insurance plan should cover most of the cost.

Answer is C. A combination of psychotherapy and medication appears to provide the best results for treatment of BPD. Medications can be useful in reducing anxiety, depression, and disruptive impulses. Relief of such symptoms may help the individual deal with harmful patterns of thinking and interacting that disrupt daily activities.
However, medications do not correct ingrained character difficulties. Long-term outpatient psychotherapy and group therapy (if the individual is carefully matched to the group) can be helpful.

DSM-IV-TR incorporated changes from DSM-IV in diagnostic criteria for the following:

Tourette's Disorder

Dementia of the Alzheimer's Type; Dementia Due to Other General Medical Conditions

Personality Change Due to a General Medical Condition

Exhibitionism; Frotteurism; Pedophilia; Sexual Sadism; Voyeurism

When a sexually-transmitted disease (STD) is suspected as a possible cause of symptoms associated with UTI, a good antibiotic choice is
a. A fluoroquinolone antibiotic because they are effective treatment for coliform bacteria, gonococci, and Chlamydia.
b. TMP/SMX because it is effective treatment for coliform bacteria.
c. Doxycycline because it is an effective treatment for Chlamydia, which is a very common cause of STD.
d. Ampicillin plus gentamicin to ensure clinical cure.

Answer is A. Quinolones make sense, because we know they are very effective at treating the UTI. And also, at least most of the quinolones that we use, Cipro is not that great against Chlamydia, but the other ones that we're generally using will basically treat all of these.

Which of the following diagnostic tests should be given to a patient who presents for the first time with dysphagia?

a. Barium esophagram
b. Histologic staining
c. 24-hour esophageal pH monitoring
d. None of the above

Answer is A. Use barium esophagram only in those patients who present for the first time with dysphagia. It helps us to give further information about the cause of their dysphagia. It serves as a road map before the gastroenterologist decides what kind of procedure to embark on.
Endoscopy should be indicated in patients who present for the first time with alarm symptoms, for example, dysphagia, odynophagia, anorexia, or weight loss. These are all ominous symptoms that may suggest that there is a mechanical obstruction, and there might be a lesion in the esophagus that needs to be further addressed. Also, we should consider endoscopy when we would like to exclude Barrett's esophagus.
When we should do endoscopy in these patients is unclear and remains an area of intense controversy. But recent American College of Gastroenterology practice guidelines suggest that patients who had symptoms of heartburn and acid regurgitation for at least 5 years should be endoscoped at least once to exclude Barrett's esophagus.
Twenty-four hour esophageal pH monitoring should be considered in patients who failed standard-dose PPI treatment. I would consider doing it on medication only to see if the PPI suppressed their acid properly.
In addition, some of the patients who have no documentation of EE prior to antireflux surgery should have a 24-hour esophageal pH monitoring done to demonstrate abnormal acid exposure.

Which of the following is NOT a contraindication to PTCA?

a. Left main disease
b. Presence of a single lesion
c. Chronic occlusions
d. Diabetes

B

Indications for PTCA have not changed significantly since its inception. Success and complication rates, however, have significantly improved. The method is still best applied to single vessel disease.

Which of the following is standard-of-care for acute asthma?

a. Aerosolized corticosteroids
b. Intravenous corticosteroids
c. Aerosolized beta-agonists
d. Oral beta-agonists

Answer is C. Aerosolized beta-agonists are now standard-of-care for acute asthma. Approximately two thirds of patients with acute asthma respond to treatment with nebulized albuterol sufficiently for discharge from the hospital.