gastroenterology ob 3

ERCP

• risk of pancreatitis 10-20%, after procedure, normally stay overnight to observe 
• tiny stone < 6mm can probably pass on it own. 
•  gallbladder pain attack often related to eating fatty food. 

crohn's disease
1st line treatment, mesalamine(Asacol)
2nd line or flare up, predinisone
before treat with 6-mp(mercaptopurine) or azathioprine (AZA), all patient need to check TPMT test to avoid possible bone marrow toxicity and liver toxicity.

6-TG and 6-MMP are toxic metabolites, 6-TG level between 230-400 may correlate to response and remission of IBD, but >400 will correlate with bone marrow suppression, 6-mmp greater than 5700, will correlate with liver toxicity.
89% of population has wild type TPMT, while 11% are heterozygous and has low TPMT enzyme activity, and only 27% of mutant TPMT associated with enzyme deficiency. so, even TPMT testing is performed, CBC and liver function must still be obtained.

recommendation: 

• all patient undergo baseline TPMT genotype testing, especially african american since they have lower WBC count. 
• homozygous mutant TPMT should avoid use heterozygous should start with low dose 
• normal genotype may use more aggressive dose by beginning with the target weight based dose. 
• all patients should have a CBC and liver chemistries at least every other week for 6-8 wks after beginning, and at least once every 3 months thereafter.  

angiodysplasia

eosinophilic esophagitis
http://www.medscape.org/viewarticle/560078

hepatic encephalopathy
MELD score(billirubin, creatinine, INR) patient MELD score 34, 3 month mortality >70%, transfer for liver transplantation, need 6 month sober.
Model for End-stage Liver Disease (MELD)

standard drink
12oz beer=5oz wine=1.5oz spirits=14 grams of alcohol
significant alcohol consumption >210 grams/wk in men and >140 gram/wk in women that equal 15 drinks/wk in men or 12 drinks/wk in women

multiple stomach polyps

ERCP
1,cholangiocarcinoma patient present w/ jaundice, previous history of gall bladder stone, ct 9 month ago show stones, but ct scan from this admission show long stricture in common bile duct, highly suspect soft tissue mass, possible cholangiocarcinoma, ercp went through this obstruction hardly, and did cytobrush, leave a 7cm 7fr stent for palliative purpose.
2,bile leak (another interesting story)