Gallstone size and risk for pancreatitis

Evaluation and management of acute pancreatitis

Acute pancreatitis (AP) is one of the most common gastrointestinal causes for hospi-talization in the United States. In 2015, AP accounted for approximately 390000 hospitalizations. The burden of AP is only expected to increase over time. Despite recent advances in medicine, pancreatitis continues to be associated with a substantial morbidity and mortality. The most common cause of AP is gallstones, followed closely by alcohol use. The diagnosis of pancreatitis is established with any two of three following criteria: (1) Abdominal pain consistent with that of AP; (2) Serum amylase and/or lipase greater than three times the upper limit of normal; and (3) Characteristics findings seen in cross-sectional abdominal imaging. Multiple criteria and scoring systems have been established for assessing severity of AP. The cornerstones of management include aggressive intravenous hydration, appropriate nutrition and pain management. Endoscopic retrograde cholangiopancreatography and surgery are important aspects in management of acute gallstone pancreatitis. We provide a comprehensive review of evaluation and management of AP.

Peroral cholecystoscopy with electrohydraulic lithotripsy for treatment of symptomatic cholelithiasis in end-stage liver disease (with videos)

BACKGROUND

Patients with end-stage liver disease have an increased risk of symptomatic gallstone disease, as well as complications associated with cholecystectomy. We hypothesized that peroral transpapillary cholecystoscopy with electrohydraulic lithotripsy of gallbladder stones is technically feasible and beneficial in patients who are high operative risks.

DESIGN

Observational, descriptive.

PATIENTS

Patients with Child's class C cirrhosis and with gallstone symptoms who were awaiting liver transplantation.

INTERVENTIONS

Gallbladder stenting, dilation of the cystic duct, cholecystoscopy, electrohydraulic lithotripsy, ursodiol therapy.

MAIN OUTCOME MEASUREMENTS

Gallbladder access and visualization, stone clearance, symptom relief, and complications.

RESULTS

The gallbladder wall and stones were adequately visualized. Electrohydraulic lithotripsy achieved stone clearance after two sessions. Mild postprocedure pancreatitis occurred after the first treatment. The patient remained symptom free, stent free, and stone free until a liver transplantation, which was performed 25 months later.

LIMITATIONS

Proof of concept performed in a single patient.

CONCLUSIONS

Peroral transpapillary cholecystoscopy is technically feasible. Electrohydraulic lithotripsy of gallbladder stones under direct vision can achieve stone clearance. Patients with cirrhosis who are awaiting transplantation and other high-risk surgical candidates with symptomatic gallstone disease may benefit from this treatment option. Studies to assess the efficacy and safety of this novel technique are needed before routine clinical use can be recommended.

A typology of consumers of institutional respite care

In this descriptive ethnography, a typology of consumers of institutional respite care and phases of respite care were formulated from the data collected over a 1-year period at a 24-bed hospital-based skilled nursing facility in the western United States. The sample was drawn from facility billing records, which verified the type of care under the term respite care. Using anthropological fieldwork methods, data were obtained from 14 caregiving dyads plus two care recipients who did not have family caregivers. The identified caregiver categories were depletion, maintenance, caregiver surgery or illness, and no available family caregiver. Phases of respite care provided information regarding the caregivers' experience in the process of decision making, transitioning to time away from the care recipient, and postrespite adjustment. This model has implications for the structure and process of respite care design and decision making. This may provide a promising avenue in the respite care research arena.