Management

2. Management Diagnostics Imaging studies Liver Function Test Therapeutics Surgical Therapy Nonpharmacologic Low fat diet Small frequent meals

3. Imaging: Hepatobiliary Tree Ultrasound • Rapid • Simultaneous scanning of GB, liver, bile ducts, pancreas • Accurate identification of dilated bile ducts • Not limited by jaundice, pregnancy • Guidance for fine-needle biopsy • Initial procedure of choice in investigating possible biliary tract obstruction

4. Imaging: CT scan • Simultaneous scanning of GB, liver, bile ducts, pancreas • Accurate identification of dilated bile ducts, masses • Not limited by jaundice, gas, obesity, ascites • High-resolution image • Guidance for fine-needle biopsy • Indicated for evaluation of hepatic or pancreatic masses • Procedure of choice in investigating possible biliary obstruction if diagnostic limitations prevent HBUS

5. Imaging: MRCP • Magnetic Resonance Cholangiopancreatography • Useful modality for visualizing pancreatic and biliary ducts • Has excellent sensitivity for bile duct dilatation, biliary stricture, and intraductal abnormalities • Can identify pancreatic duct dilatation or stricture, pancreatic duct stenosis, and pancreas divisum

6. Imaging: ERCP • Endoscopic Retrograde Cholangiopancreatography • Simultaneous pancreatography • Best visualization of distal biliary tract • Bile or pancreatic cytology • Endoscopic sphincterotomy and stone removal • Biliarymanometry •  Endoscopic sphincterotomy a treatment possibility

7. Imaging: PTC • PercutaneousTranshepaticCholangiogram • Extremely successful when bile ducts dilated • Best visualization of proximal biliary tract • Bile cytology/culture • Percutaneoustranshepatic drainage • Indicated when ERCP is contraindicated or failed

8. Liver Function Test • Alkaline Phosphatase- elevated (>4 times) suggests intra- and extrahepaticcholestasis (N: 30 to 120 IU/L) • Aminotransferases: suggests Liver damage • Elevated ALT- may suggests Alcoholic Hepatitis (N: 9 to 60 IU/L) • Elevated AST- may suggests viral or drug hepatitis (N: 10 to 40 IU/L) • Serum bilirubin • Conjugated- cholestasis (N: 0–0.3 mg/dL)

9. Therapeutics • Surgical a. Open Cholecystectomy b. Laparoscopic Cholecystectomy- safe and effective in children, elderly, pregnant woman on 2nd trimester • About 90% of patients with typical biliary symptoms and stones are rendered symptom free after cholecystectomy (open or laparoscopic). For patients with atypical symptoms or dyspepsia (flatulence, belching, bloating, and dietary fat intolerance) the results are not as favorable. 2. Nonpharmacologic a. avoid dietary fats and large meals. b. Small frequent meals

10. Choose • Oils Olive oil, canola oil, nonstick cooking spray, safflower oil, flavored oils • Canned Fish Water-packed tuna, salmon and sardines • Canned Vegetables and Fruit Peas, carrots, corn, beets, mushrooms, asparagus; peaches, pineapple, pears - in light syrup • Canned Tomatoes Whole, diced or crushed tomatoes, tomato purees, tomato sauces (with no added salt) • Legumes and Grains Canned or dried black beans, pinto beans, chickpeas (Garbanzo beans), kidney beans, navy beans, black-eyed peas; rice, lentils, barley, couscous, quinoa, bulgur, kamut • Pasta Whole wheat spaghetti, penne, lasagna sheets and other noodles • Jars Anchovies, capers, pimientos, peppers, artichokes, pickles, sundried tomatoes, minced garlic • Soups and Stocks Low-fat, low-sodium canned soups and soup mixes; low-sodium, fat-free broths, bouillon cubes and stock concentrates

11. Choose • Flavorings Herbs, spices and seasonings; whole garlic, garlic paste, tomato paste, chili paste, bottled ginger, low-sodium Worcestershire sauce, soy sauces and bottled marinades • Dressings Vinegars, mustards, low-fat or fat-free salad dressings and mayonnaise • Breads and Cereals Whole grain breads, rolls and bagels; whole wheat flour; whole-grain cereals such as oatmeal, bran flakes or low-fat granola • Dried Fruits Cranberries, cherries, blueberries and raisins • Nuts and Seeds Almonds, hazelnuts, walnuts, peanuts, pecans; pumpkin seeds, sunflower seeds, sesame seeds, poppy seeds, and flax seeds • Sugars Honey, molasses, maple syrup • Snacks Pretzels, low-fat microwave popcorn, whole grain crackers; sugar-free/fat-free pudding and jello, applesauce

12. Lose • Regular mayonnaise and oil-based dressings • Shortening, though there is at least a trans fat-free version available • Oil-packed tuna and fish • Canned meats • Cream soups and chowders • Boxed mac and cheese • Flavored pasta and rice mixes • Refried beans, unless fat free

13. Lose • Gravy mixes, cheese sauces, pancake and biscuit mixes • Sugary cereals • Anything with "partially hydrogenated" on the label (cookies, cakes, donuts, muffins) • Potato chips, corn chips, unless baked • White bread • Coffee creamer

14. Others • Milkaim for nonfat milk at best, and 1% milk at least. Choose low-fat or nonfat ice creams or yogurts over full fat versions, and do the same for sour cream. • CheeseChoose low-fat or fat-free cottage cheese, cream cheese and hard cheeses. • Eggsuse egg whites, use whole eggs sparingly. • MeatFresh meat should be as lean as possible. Watch out for sodium content in the latter. Try veggie burgers instead of beef patties • FishFish should be consumed at least twice a week. Fish oils contain high levels of heart-healthy omega-3 fatty acids.