Midepigastric Pain

The Gallstone Elimination Report

Gallstone Elimination Manual by David Smith

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Midepigastric pain is associated with early stages of acute appendicitis, acute small bowel obstruction, peptic ulcer disease, and acute pancreatitis. Pancreatitis, depending on the etiology of the inflammation, including gallstones, alcohol or idiopathic causes, requires different types of intervention. Gallstone pancreatitis is one of the few types of pancreatitis that require early surgical intervention.

It occurs when gallstones become lodged in the pancreatic duct causing obstruction and inflammation. Treatment involves admission for bowel rest and intravenous fluid hydration until the obstructing stone passes and the pancreatitis resolves. This is seen with cessation of clinical symptoms of pancreatitis and normalization of amylase and lipase serum levels. After resolution of the acute pancreatitic flare, the patient should undergo cholecystectomy during the same hospital admission as he or she will be at increased risk of having recurrent pancreatitis until the source of the gallstones is removed. Preoperative biliary decompression by ERCP or PTC may be required if the obstructing stone does not pass spontaneously. An intraoperative cholangiogram may be required in order to ensure no further gallstones are present in the biliary system.

Acute necrotizing pancreatitis is a severe form of pancreatitis that may require surgical intervention. It is seen in approximately 20 percent of all cases of pancreatitis. Necrosis alone is not an automatic indication for surgery. If the necrosis remains sterile, the patient should be treated with bowel rest until the pancreatitis resolves. The sequelae from the necrosis, including pancreatic pseudocysts and abscesses should be watched for and treated if the patient becomes symptomatic. The indication for operative intervention in necrotizing pancreatitis is hemodynamic instability. This is usually due to sepsis when the necrosis becomes infected. In these cases, mortality for untreated infected pancreatic necrosis approaches 90-100 percent. Many clinicians argue that pancreatic necrosis seen on CT scan should not be biopsied until the patient starts exhibiting clinical signs of sepsis as this could be a means of introducing infection into an otherwise sterile pancreatic phlegmon.

Other causes of midepigastric pain include gastroesophageal reflux disease (GERD), gastric and duodenal ulcer disease with or without perforation, and cardiac symptoms. All diseases should be ruled out per the risk factors seen in that patient. For example, if a 65-year-old gentleman with a known history of reflux presents to the ED complaining of midepigastric pain, even though the pain may be recurrent reflux, he should still get at the least an ECG to ensure that there is no cardiac ischemia occurring. GERD is treated surgically under specific criteria, including patients who are refractory to medical therapy, people who are noncompliant with their medications, and people with pathologic changes of dysplasia or malignancy secondary to reflux seen during esophagogastroduodenoscopy (EGD) evaluation. Reflux surgery is rarely done urgently. Ulcer disease has been seen to be highly correlated with Helicobacter pylori infection, which is treated initially with medical therapy. Patients with ulcer disease on initial diagnosis as well as when the disease is refractory to medical therapy should receive endo-scopic evaluation with biopsies to rule out malignancy.

Perforated ulcers should be treated urgently. These patients often present with free air and sepsis. Specific surgical management is dependent on their previous history, so it is essential to ask some questions prior to induction of anesthesia. Patients should be asked about antacid therapy, including proton pump inhibitors, as well as nonsteroidal inflammatory agent use. Previous history of H. pylori infection and treatment is also important for surgical decision making. An assessment as to likely postoperative medical compliance should also be obtained. After this brief history, the patient should be resuscitated and taken to surgery.

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Get Rid of Gallstones Naturally

Get Rid of Gallstones Naturally

One of the main home remedies that you need to follow to prevent gallstones is a healthy lifestyle. You need to maintain a healthy body weight to prevent gallstones. The following are the best home remedies that will help you to treat and prevent gallstones.

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