Nancy J. Sugarek

Clinical evaluation for gallstone disease: Usefulness of symptoms and signs in diagnosis

PURPOSE Patients with gallstones who have recently experienced biliary tract pain are likely to develop recurrent symptoms in the near future. As a consequence, most symptomatic patients are offered specific treatment. However, disagreement persists regarding which symptoms and signs truly represent symptomatic cholelithiasis. We re-examined the relation of gastrointestinal complaints and physical findings to the presence of gallstones in a clinical population. PATIENTS AND METHODS Over a 2-year period, we identified outpatients of a public teaching hospital for whom diagnostic studies of the gallbladder had been ordered. Patients were interviewed and examined by research personnel prior to completion of the studies. Gastrointestinal symptoms and physical examination findings in 122 patients found to have gallstones were contrasted with those of 178 gallstone-free patients. RESULTS In comparison to control subjects, patients with gallstones more often reported epigastric pain lasting at least 30 minutes (64.2% versus 45.1%, p less than 0.004). The latter patients infrequently complained of lower abdominal pain (12.3% versus 29.9%, p less than 0.002), but more often described pain radiating to the upper back. Gallstone-associated pain usually occurred more than 1 hour after meals, persisted from 1 to 24 hours, and was steady in quality. Although these differences were statistically significant, likelihood ratio analysis indicated that clinical symptoms and signs were relatively weak discriminators of gallbladder disease. CONCLUSIONS Upper abdominal pain is the symptom most closely associated with gallstone disease. Radiation to the upper back, a steady quality, duration between 1 and 24 hours, and onset more than an hour after meals support the diagnosis. Nevertheless, gallstone-associated symptoms are non-specific, and accurate diagnosis cannot rely on the clinical assessment alone. Careful clinical evaluation can guide patient selection for diagnostic imaging and the appropriate management of those found to harbor stones.

Medication Compliance in Non-insulin-dependent Diabetes: A Randomized Comparison of Chlorpropamide and Insulin

Medication compliance may be a problem in the management of patients with diabetes. Some physicians initially treat patients having non-insulin-dependent diabetes with oral sulfonylureas because they fear greater compliance problems with insulin therapy. We compared compliance with insulin and chlorpropamide in patients newly beginning medication for NIDDM. Seventy-seven adults with hyperglycemia despite diet therapy were randomly assigned to chlorpropamide or insulin. Compliance was measured four times over 24 wk. Patients then crossed over to the other medication and were followed for 24 additional weeks. Overall, there were no differences in compliance with the two medications in terms of percent of prescription used, proportion taking at least 80% of prescribed medication, self-report of medication or diet compliance, or protocol dropout rates. However, treatment satisfaction was higher with chlorpropamide, and most patients preferred chlorpropamide to insulin (P < 0.0001). While such differences in satisfaction may affect long-term compliance, physicians should not assume that their patients will be less compliant with insulin than with oral sulfonylureas.

Clinical and sociocultural determinants of gallstone treatment

Cholecystectomy remains the principal treatment for gallstones. Many gallstone patients do not undergo surgery within 6 months of diagnosis. To determine factors associated with cholecystectomy, treated and untreated patients were compared with respect to clinical and sociodemographic factors. The study population was comprised of outpatients of a public system evaluated in an emergency room or at a community health center. All were interviewed in English or Spanish before completing imaging studies. Of 121 found to have gallstones, 75 underwent early cholecystectomy. Patients reporting episodes of prolonged abdominal pain more often had surgery (p < 0.003). Patients evaluated in the emergency room underwent surgery more often than those from the community health center (p < 0.04). Patient ethnicity was unrelated to treatment, but Mexican Americans who requested interviews in Spanish were less likely to undergo cholecystectomy (p < 0.05). After logistic regression, prolonged abdominal pain was the only significant predictor of surgical management, although relationships with language use and site of diagnosis persisted. It was concluded that clinical presentation largely determines surgical treatment for gallstones but site of diagnosis is also a factor. Patients with poor English language skills undergo cholecystectomy less often. This may be due to poor doctor-patient communication, or it may be a reflection of cultural factors linked to language use.

Clinically Significant Diuretic-Induced Glucose Intolerance

Diuretic-induced glucose intolerance is cited frequently as a problem of only limited clinical significance. In certain populations, such as Mexican-Americans, this effect may be much more dramatic. A 50-year-old obese Mexican-American woman presented with a three-month history of increased thirst and frequent urination. A fasting blood glucose concentration of 365 mg/dL prompted initiation of chlorpropamide therapy. A review of her medical history revealed that a thiazide diuretic was started six months previously. A reduction in thiazide dose and potassium supplementation together with chlorpropamide therapy controlled the patients blood glucose. Subsequently, all three medications were discontinued, and the patient remained normoglycemic during a full year of follow-up. The temporal relationship between symptomatic diabetes and hydrochlorothiazide therapy incriminates the diuretic as the most probable cause.