Gallstones (Cholelithiasis)_ Practice Essentials, Background, Pathophysiology

10/13/2015 Gallstones(Cholelithiasis):PracticeEssentials,Background,Pathophysiology

http://emedicine.medscape.com/article/175667overview 1/8

Gallstones(Cholelithiasis)Author:DouglasMHeuman,MD,FACP,FACG,AGAFChiefEditor:JulianKatz,MDmore...

Updated:Jan20,2015

PracticeEssentialsCholelithiasisinvolvesthepresenceofgallstones(seetheimagebelow),whichareconcretionsthatforminthebiliarytract,usuallyinthegallbladder.Choledocholithiasisreferstothepresenceof1ormoregallstonesinthecommonbileduct(CBD).Treatmentofgallstonesdependsonthestageofdisease.

Magneticresonancecholangiopancreatography(MRCP)showing5gallstonesinthecommonbileduct(arrows).Inthisimage,bileintheductappearswhitestonesappearasdarkfillingdefects.Similarimagescanbeobtainedbytakingplainradiographsafterinjectionofradiocontrastmaterialinthecommonbileduct,eitherendoscopically(endoscopicretrogradecholangiography)orpercutaneouslyunderfluoroscopicguidance(percutaneoustranshepaticcholangiography),buttheseapproachesaremoreinvasive.

Signsandsymptoms

Gallstonediseasemaybethoughtofashavingthefollowing4stages:

1. Lithogenicstate,inwhichconditionsfavorgallstoneformation2. Asymptomaticgallstones3. Symptomaticgallstones,characterizedbyepisodesofbiliarycolic4. Complicatedcholelithiasis

SymptomsandcomplicationsresultfromeffectsoccurringwithinthegallbladderorfromstonesthatescapethegallbladdertolodgeintheCBD.

Characteristicsofbiliarycolicincludethefollowing:

SporadicandunpredictableepisodesPainthatislocalizedtotheepigastriumorrightupperquadrant,sometimesradiatingtotherightscapulartipPainthatbeginspostprandially,isoftendescribedasintenseanddull,typicallylasts15hours,increasessteadilyover1020minutes,andthengraduallywanesPainthatisconstantnotrelievedbyemesis,antacids,defecation,flatus,orpositionalchangesandsometimesaccompaniedbydiaphoresis,nausea,andvomitingNonspecificsymptoms(eg,indigestion,dyspepsia,belching,orbloating)

Patientswiththelithogenicstateorasymptomaticgallstoneshavenoabnormalfindingsonphysicalexamination.

Distinguishinguncomplicatedbiliarycolicfromacutecholecystitisorothercomplicationsisimportant.Keyfindingsthatmaybenotedincludethefollowing:

UncomplicatedbiliarycolicPainthatispoorlylocalizedandvisceralanessentiallybenignabdominalexaminationwithoutreboundorguardingabsenceoffeverAcutecholecystitisWelllocalizedpainintherightupperquadrant,usuallywithreboundandguardingpositiveMurphysign(nonspecific)frequentpresenceoffeverabsenceofperitonealsignsfrequentpresenceoftachycardiaanddiaphoresisinseverecases,absentorhypoactivebowelsounds

Thepresenceoffever,persistenttachycardia,hypotension,orjaundicenecessitatesasearchforcomplications,whichmayincludethefollowing:

CholecystitisCholangitisPancreatitisOthersystemiccauses

SeePresentationformoredetail.

Diagnosis



Patientswithuncomplicatedcholelithiasisorsimplebiliarycolictypicallyhavenormallaboratorytestresultslaboratorystudiesaregenerallynotnecessaryunlesscomplicationsaresuspected.Bloodtests,whenindicated,mayincludethefollowing:

Completebloodcount(CBC)withdifferentialLiverfunctionpanelAmylaseLipase

Imagingmodalitiesthatmaybeusefulincludethefollowing:

Abdominalradiography(uprightandsupine)Usedprimarilytoexcludeothercausesofabdominalpain(eg,intestinalobstruction)UltrasonographyTheprocedureofchoiceinsuspectedgallbladderorbiliarydiseaseEndoscopicultrasonography(EUS)AnaccurateandrelativelynoninvasivemeansofidentifyingstonesinthedistalCBDLaparoscopicultrasonographyPromisingasapotentialmethodforbileductimagingduringlaparoscopiccholecystectomyComputedtomography(CT)Moreexpensiveandlesssensitivethanultrasonographyfordetectinggallbladderstones,butsuperiorfordemonstratingstonesinthedistalCBDMagneticresonanceimaging(MRI)withmagneticresonancecholangiopancreatography(MRCP)UsuallyreservedforcasesinwhichcholedocholithiasisissuspectedScintigraphyHighlyaccurateforthediagnosisofcysticductobstructionEndoscopicretrogradecholangiopancreatography(ERCP)Percutaneoustranshepaticcholangiography(PTC)

SeeWorkupformoredetail.

Management

Thetreatmentofgallstonesdependsuponthestageofdisease,asfollows:

LithogenicstateInterventionsarecurrentlylimitedtoafewspecialcircumstancesAsymptomaticgallstonesExpectantmanagementSymptomaticgallstonesUsually,definitivesurgicalintervention(eg,cholecystectomy),thoughmedicaldissolutionmaybeconsideredinsomecases

Medicaltreatments,usedindividuallyorincombination,includethefollowing:

Oralbilesalttherapy(ursodeoxycholicacid)ContactdissolutionExtracorporealshockwavelithotripsy

Cholecystectomyforasymptomaticgallstonesmaybeindicatedinthefollowingpatients:

Thosewithlarge(>2cm)gallstonesThosewhohaveanonfunctionalorcalcified(porcelain)gallbladderonimagingstudiesandwhoareathighriskofgallbladdercarcinomaThosewithspinalcordinjuriesorsensoryneuropathiesaffectingtheabdomenThosewithsicklecellanemiainwhomthedistinctionbetweenpainfulcrisisandcholecystitismaybedifficult

Patientswiththefollowingriskfactorsforcomplicationsofgallstonesmaybeofferedelectivecholecystectomy,eveniftheyhaveasymptomaticgallstones:

CirrhosisPortalhypertensionChildrenTransplantcandidatesDiabeteswithminorsymptoms

Surgicalinterventionstobeconsideredincludethefollowing:

Cholecystectomy(openorlaparoscopic)CholecystostomyEndoscopicsphincterotomy

SeeTreatmentandMedicationformoredetail.

BackgroundCholelithiasisisthemedicaltermforgallstonedisease.Gallstonesareconcretionsthatforminthebiliarytract,usuallyinthegallbladder(seetheimagebelow).



Excisedgallbladderopenedtoshow3gallstones

Gallstonesdevelopinsidiously,andtheymayremainasymptomaticfordecades.Migrationofaagallstoneintotheopeningofthecysticductmayblocktheoutflowofbileduringgallbladdercontraction.Theresultingincreaseingallbladderwalltensionproducesacharacteristictypeofpain(biliarycolic).Cysticductobstruction,ifitpersistsformorethanafewhours,mayleadtoacutegallbladderinflammation(acutecholecystitis).

Choledocholithiasisreferstothepresenceofoneormoregallstonesinthecommonbileduct.Usually,thisoccurswhenagallstonepassesfromthegallbladderintothecommonbileduct(seetheimagebelow).

Commonbileductstone(choledocholithiasis).Thesensitivityoftransabdominalultrasonographyforcholedocholithiasisisapproximately75%inthepresenceofdilatedductsand50%fornondilatedducts.ImagecourtesyofDTSchwartz.

AgallstoneinthecommonbileductmayimpactdistallyintheampullaofVater,thepointwherethecommonbileductandpancreaticductjoinbeforeopeningintotheduodenum.Obstructionofbileflowbyastoneatthiscriticalpointmayleadtoabdominalpainandjaundice.Stagnantbileaboveanobstructingbileductstoneoftenbecomesinfected,andbacteriacanspreadrapidlybackuptheductalsystemintothelivertoproducealifethreateninginfectioncalledascendingcholangitis.ObstructionofthepancreaticductbyagallstoneintheampullaofVateralsocantriggeractivationofpancreaticdigestiveenzymeswithinthepancreasitself,leadingtoacutepancreatitis.[1,2]

Chronically,gallstonesinthegallbladdermaycauseprogressivefibrosisandlossoffunctionofthegallbladder,aconditionknownaschroniccholecystitis.Chroniccholecystitispredisposestogallbladdercancer.

Ultrasonographyistheinitialdiagnosticprocedureofchoiceinmostcasesofsuspectedgallbladderorbiliarytractdisease(seeWorkup).

Thetreatmentofgallstonesdependsuponthestageofdisease.Asymptomaticgallstonesmaybemanagedexpectantly.Oncegallstonesbecomesymptomatic,definitivesurgicalinterventionwithexcisionofthegallbladder(cholecystectomy)isusuallyindicated.Cholecystectomyisamongthemostfrequentlyperformedabdominalsurgicalprocedures(seeTreatment).Complicationsofgallstonediseasemayrequirespecializedmanagementtorelieveobstructionandinfection.

GotoPediatricCholelithiasisforcompleteinformationonthistopic.

PathophysiologyGallstoneformationoccursbecausecertainsubstancesinbilearepresentinconcentrationsthatapproachthelimitsoftheirsolubility.Whenbileisconcentratedinthegallbladder,itcanbecomesupersaturatedwiththesesubstances,whichthenprecipitatefromsolutionasmicroscopiccrystals.Thecrystalsaretrappedingallbladdermucus,producinggallbladdersludge.Overtime,thecrystalsgrow,aggregate,andfusetoformmacroscopicstones.Occlusionoftheductsbysludgeand/orstonesproducesthecomplicationsofgallstonedisease.

The2mainsubstancesinvolvedingallstoneformationarecholesterolandcalciumbilirubinate.

Cholesterolgallstones

Morethan80%ofgallstonesintheUnitedStatescontaincholesterolastheirmajorcomponent.Livercellssecretecholesterolintobilealongwithphospholipid(lecithin)



intheformofsmallsphericalmembranousbubbles,termedunilamellarvesicles.Livercellsalsosecretebilesalts,whicharepowerfuldetergentsrequiredfordigestionandabsorptionofdietaryfats.

Bilesaltsinbiledissolvetheunilamellarvesiclestoformsolubleaggregatescalledmixedmicelles.Thishappensmainlyinthegallbladder,wherebileisconcentratedbyreabsorptionofelectrolytesandwater.

Comparedwithvesicles(whichcanholdupto1moleculeofcholesterolforeverymoleculeoflecithin),mixedmicelleshavealowercarryingcapacityforcholesterol(about1moleculeofcholesterolforevery3moleculesoflecithin).Ifbilecontainsarelativelyhighproportionofcholesteroltobeginwith,thenasbileisconcentrated,progressivedissolutionofvesiclesmayleadtoastateinwhichthecholesterolcarryingcapacityofthemicellesandresidualvesiclesisexceeded.Atthispoint,bileissupersaturatedwithcholesterol,andcholesterolmonohydratecrystalsmayform.

Thus,themainfactorsthatdeterminewhethercholesterolgallstoneswillformare(1)theamountofcholesterolsecretedbylivercells,relativetolecithinandbilesalts,and(2)thedegreeofconcentrationandextentofstasisofbileinthegallbladder.

Calcium,bilirubin,andpigmentgallstones

Bilirubin,ayellowpigmentderivedfromthebreakdownofheme,isactivelysecretedintobilebylivercells.Mostofthebilirubininbileisintheformofglucuronideconjugates,whicharequitewatersolubleandstable,butasmallproportionconsistsofunconjugatedbilirubin.Unconjugatedbilirubin,likefattyacids,phosphate,carbonate,andotheranions,tendstoforminsolubleprecipitateswithcalcium.Calciumentersbilepassivelyalongwithotherelectrolytes.

Insituationsofhighhemeturnover,suchaschronichemolysisorcirrhosis,unconjugatedbilirubinmaybepresentinbileathigherthannormalconcentrations.Calciumbilirubinatemaythencrystallizefromsolutionandeventuallyformstones.Overtime,variousoxidationscausethebilirubinprecipitatestotakeonajetblackcolor,andstonesformedinthismanneraretermedblackpigmentgallstones.Blackpigmentstonesrepresent1020%ofgallstonesintheUnitedStates.

Bileisnormallysterile,butinsomeunusualcircumstances(eg,aboveabiliarystricture),itmaybecomecolonizedwithbacteria.Thebacteriahydrolyzeconjugatedbilirubin,andtheresultingincreaseinunconjugatedbilirubinmayleadtoprecipitationofcalciumbilirubinatecrystals.

Bacteriaalsohydrolyzelecithintoreleasefattyacids,whichalsomaybindcalciumandprecipitatefromsolution.Theresultingconcretionshaveaclaylikeconsistencyandaretermedbrownpigmentstones.Unlikecholesterolorblackpigmentgallstones,whichformalmostexclusivelyinthegallbladder,brownpigmentgallstonesoftenformdenovointhebileducts.BrownpigmentgallstonesareunusualintheUnitedStatesbutarefairlycommoninsomepartsofSoutheastAsia,possiblyrelatedtoliverflukeinfestation.

Mixedgallstones

Cholesterolgallstonesmaybecomecolonizedwithbacteriaandcanelicitgallbladdermucosalinflammation.Lyticenzymesfrombacteriaandleukocyteshydrolyzebilirubinconjugatesandfattyacids.Asaresult,overtime,cholesterolstonesmayaccumulateasubstantialproportionofcalciumbilirubinateandothercalciumsalts,producingmixedgallstones.Largestonesmaydevelopasurfacerimofcalciumresemblinganeggshellthatmaybevisibleonplainxrayfilms.

EtiologyCholesterolgallstones,blackpigmentgallstones,andbrownpigmentgallstoneshavedifferentpathogenesesanddifferentriskfactors.

Cholesterolgallstones

Cholesterolgallstonesareassociatedwithfemalesex,EuropeanorNativeAmericanancestry,andincreasingage.Otherriskfactorsincludethefollowing:

ObesityPregnancyGallbladderstasisDrugsHeredity

Themetabolicsyndromeoftruncalobesity,insulinresistance,typeIIdiabetesmellitus,hypertension,andhyperlipidemiaisassociatedwithincreasedhepaticcholesterolsecretionandisamajorriskfactorforthedevelopmentofcholesterolgallstones.

Cholesterolgallstonesaremorecommoninwomenwhohaveexperiencedmultiplepregnancies.Amajorcontributingfactoristhoughttobethehighprogesteronelevelsofpregnancy.Progesteronereducesgallbladdercontractility,leadingtoprolongedretentionandgreaterconcentrationofbileinthegallbladder.

Othercausesofgallbladderstasisassociatedwithincreasedriskofgallstonesincludehighspinalcordinjuries,prolongedfastingwithtotalparenteralnutrition,andrapidweightlossassociatedwithseverecaloricandfatrestriction(eg,diet,gastricbypasssurgery).

Anumberofmedicationsareassociatedwithformationofcholesterolgallstones.Estrogensadministeredforcontraceptionorfortreatmentofprostatecancerincreasetheriskofcholesterolgallstonesbyincreasingbiliarycholesterolsecretion.Clofibrateandotherfibratehypolipidemicdrugsincreasehepaticeliminationofcholesterolviabiliarysecretionandappeartoincreasetheriskofcholesterolgallstones.Somatostatinanaloguesappeartopredisposetogallstonesby



decreasinggallbladderemptying.

About25%ofthepredispositiontocholesterolgallstonesappearstobehereditary,asjudgedfromstudiesofidenticalandfraternaltwins.Atleastadozengenesmaycontributetotherisk.[3]Araresyndromeoflowphospholipidassociatedcholelithiasisoccursinindividualswithahereditarydeficiencyofthebiliarytransportproteinrequiredforlecithinsecretion.[4]

Blackandbrownpigmentgallstones

Blackpigmentgallstonesoccurdisproportionatelyinindividualswithhighhemeturnover.Disordersofhemolysisassociatedwithpigmentgallstonesincludesicklecellanemia,hereditaryspherocytosis,andbetathalassemia.Incirrhosis,portalhypertensionleadstosplenomegaly.This,inturn,causesredcellsequestration,leadingtoamodestincreaseinhemoglobinturnover.Abouthalfofallcirrhoticpatientshavepigmentgallstones.

Prerequisitesforformationofbrownpigmentgallstonesincludeintraductalstasisandchroniccolonizationofbilewithbacteria.IntheUnitedStates,thiscombinationismostoftenencounteredinpatientswithpostsurgicalbiliarystricturesorcholedochalcysts.

InricegrowingregionsofEastAsia,infestationwithbiliaryflukesmayproducebiliarystricturesandpredisposetoformationofbrownpigmentstonesthroughoutintrahepaticandextrahepaticbileducts.Thiscondition,termedhepatolithiasis,causesrecurrentcholangitisandpredisposestobiliarycirrhosisandcholangiocarcinoma.

Othercomorbidities

Crohndisease,ilealresection,orotherdiseasesoftheileumdecreasebilesaltreabsorptionandincreasetheriskofgallstoneformation.

Otherillnessesorstatesthatpredisposetogallstoneformationincludeburns,useoftotalparenteralnutrition,paralysis,ICUcare,andmajortrauma.Thisisdue,ingeneral,todecreasedenteralstimulationofthegallbladderwithresultantbiliarystasisandstoneformation.

EpidemiologyTheprevalenceofcholelithiasisisaffectedbymanyfactors,includingethnicity,gender,comorbidities,andgenetics.

UnitedStatesstatistics

IntheUnitedStates,about20millionpeople(1020%ofadults)havegallstones.Everyyear13%ofpeopledevelopgallstonesandabout13%ofpeoplebecomesymptomatic.Eachyear,intheUnitedStates,approximately500,000peopledevelopsymptomsorcomplicationsofgallstonesrequiringcholecystectomy.

Gallstonediseaseisresponsibleforabout10,000deathsperyearintheUnitedStates.About7000deathsareattributabletoacutegallstonecomplications,suchasacutepancreatitis.About20003000deathsarecausedbygallbladdercancers(80%ofwhichoccurinthesettingofgallstonediseasewithchroniccholecystitis).Althoughgallstonesurgeryisrelativelysafe,cholecystectomyisaverycommonprocedure,anditsrarecomplicationsresultinseveralhundreddeathseachyear.

Internationalstatistics

TheprevalenceofcholesterolcholelithiasisinotherWesternculturesissimilartothatintheUnitedStates,butitappearstobesomewhatlowerinAsiaandAfrica.

ASwedishepidemiologicstudyfoundthattheincidenceofgallstoneswas1.39per100personyears.[5]InanItalianstudy,20%ofwomenhadstones,and14%ofmenhadstones.InaDanishstudy,gallstoneprevalenceinpersonsaged30yearswas1.8%formenand4.8%forwomengallstoneprevalenceinpersonsaged60yearswas12.9%formenand22.4%forwomen.

TheprevalenceofcholedocholithiasisishigherinternationallythanintheUnitedStates,mainlybecauseoftheadditionalproblemofprimarycommonbileductstonescausedbyparasiticinfestationwithliverflukessuchasClonorchissinensis.

Race,sex,andagerelateddemographics

PrevalenceofgallstonesishighestinpeopleofnorthernEuropeandescent,andinHispanicpopulationsandNativeAmericanpopulations.[6]PrevalenceofgallstonesislowerinAsiansandAfricanAmericans.

Womenaremorelikelytodevelopcholesterolgallstonesthanmen,especiallyduringtheirreproductiveyears,whentheincidenceofgallstonesinwomenis23timesthatinmen.Thedifferenceappearstobeattributablemainlytoestrogen,whichincreasesbiliarycholesterolsecretion.[7]

Riskofdevelopinggallstonesincreaseswithage.Gallstonesareuncommoninchildrenintheabsenceofcongenitalanomaliesorhemolyticdisorders.Beginningatpuberty,theconcentrationofcholesterolinbileincreases.Afterage15years,theprevalenceofgallstonesinUSwomenincreasesbyabout1%peryearinmen,therateisless,about0.5%peryear.Gallstonescontinuetoformthroughoutadultlife,andtheprevalenceisgreatestatadvancedage.Theincidenceinwomenfallswithmenopause,butnewstoneformationinmenandwomencontinuesatarateofabout0.4%peryearuntillateinlife.

Amongindividualsundergoingcholecystectomyforsymptomaticcholelithiasis,815%ofpatientsyoungerthan60yearshavecommonbileductstones,comparedwith1560%ofpatientsolderthan60years.



PrognosisLessthanhalfofpatientswithgallstonesbecomesymptomatic.Themortalityrateforanelectivecholecystectomyis0.5%withlessthan10%morbidity.Themortalityrateforanemergentcholecystectomyis35%with3050%morbidity.

Followingcholecystectomy,stonesmayrecurinthebileduct.

Approximately1015%ofpatientshaveanassociatedcholedocholithiasis.Theprognosisinpatientswithcholedocholithiasisdependsonthepresenceandseverityofcomplications.Ofallpatientswhorefusesurgeryorareunfittoundergosurgery,45%remainasymptomaticfromcholedocholithiasis,while55%experiencevaryingdegreesofcomplications.

PatientEducationPatientswithasymptomaticgallstonesshouldbeeducatedtorecognizeandreportthesymptomsofbiliarycolicandacutepancreatitis.Alarmsymptomsincludepersistentepigastricpainlastingforgreaterthan20minutes,especiallyifaccompaniedbynausea,vomiting,orfever.Ifpainissevereorpersistsformorethananhour,thepatientshouldseekimmediatemedicalattention.

Forpatienteducationinformation,seetheLiver,Gallbladder,andPancreasCenterandCholesterolCenter,aswellasGallstones.

ClinicalPresentation

ContributorInformationandDisclosuresAuthorDouglasMHeuman,MD,FACP,FACG,AGAFChiefofHepatology,HunterHolmesMcGuireDepartmentofVeteransAffairsMedicalCenterProfessor,DepartmentofInternalMedicine,DivisionofGastroenterology,VirginiaCommonwealthUniversitySchoolofMedicine

DouglasMHeuman,MD,FACP,FACG,AGAFisamemberofthefollowingmedicalsocieties:AmericanAssociationfortheStudyofLiverDiseases,AmericanCollegeofPhysicians,AmericanGastroenterologicalAssociation

Disclosure:Receivedgrant/researchfundsfromNovartisforotherReceivedgrant/researchfundsfromBayerforotherReceivedgrant/researchfundsfromOtsukafornoneReceivedgrant/researchfundsfromBristolMyersSquibbforotherReceivednonefromScynexisfornoneReceivedgrant/researchfundsfromSalixforotherReceivedgrant/researchfundsfromMannKindforother.

Coauthor(s)JeffAllen,MDAssistantProfessor,DepartmentofSurgery,UniversityofLouisville

Disclosure:Nothingtodisclose.

AnastasiosAMihas,MD,DMSc,FACP,FACGProfessor,DepartmentofMedicine,DivisionofGastroenterology,VirginiaCommonwealthUniversitySchoolofMedicineConsultingStaff,VirginiaCommonwealthUniversityHospitalsandClinicsChiefofGIClinicalResearch,DirectorofGIOutpatientService,AssociateDirectorofHepatology,HunterHolmesMcGuireVeteransAffairsMedicalCenter

AnastasiosAMihas,MD,DMSc,FACP,FACGisamemberofthefollowingmedicalsocieties:AmericanAssociationfortheStudyofLiverDiseases,AmericanCollegeofGastroenterology,AmericanCollegeofPhysicians,AmericanGastroenterologicalAssociation,AmericanSocietyforGastrointestinalEndoscopy,SigmaXi,SouthernSocietyforClinicalInvestigation,AmericanFederationforClinicalResearch,GastroenterologyResearchGroup


ChiefEditorJulianKatz,MDClinicalProfessorofMedicine,DrexelUniversityCollegeofMedicine

JulianKatz,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofGastroenterology,AmericanCollegeofPhysicians,AmericanGastroenterologicalAssociation,AmericanGeriatricsSociety,AmericanMedicalAssociation,AmericanSocietyforGastrointestinalEndoscopy,AmericanSocietyofLaw,Medicine&Ethics,AmericanTraumaSociety,AssociationofAmericanMedicalColleges,PhysiciansforSocialResponsibility


AcknowledgementsFirassAbiad,MDHeadofDivision,GeneralandLaparoscopicSurgery,SpecializedMedicalCenterHospital,SaudiArabia


BSAnand,MDProfessor,DepartmentofInternalMedicine,DivisionofGastroenterology,BaylorCollegeofMedicine

BSAnand,MDisamemberofthefollowingmedicalsocieties:AmericanAssociationfortheStudyofLiverDiseases,AmericanCollegeofGastroenterology,AmericanGastroenterologicalAssociation,andAmericanSocietyforGastrointestinalEndoscopy


DavidEricBernstein,MDDirectorofHepatology,NorthShoreUniversityHospitalProfessorofClinicalMedicine,AlbertEinsteinCollegeofMedicine

DavidEricBernstein,MDisamemberofthefollowingmedicalsocieties:AmericanAssociationfortheStudyofLiverDiseases,AmericanCollegeofGastroenterology,AmericanCollegeofPhysicians,AmericanGastroenterologicalAssociation,andAmericanSocietyforGastrointestinalEndoscopy


BarryEBrenner,MD,PhD,FACEPProfessorofEmergencyMedicine,ProfessorofInternalMedicine,



ProgramDirector,EmergencyMedicine,CaseMedicalCenter,UniversityHospitals,CaseWesternReserveUniversitySchoolofMedicine

BarryEBrenner,MD,PhD,FACEPisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,AmericanAcademyofEmergencyMedicine,AmericanCollegeofChestPhysicians,AmericanCollegeofEmergencyPhysicians,AmericanCollegeofPhysicians,AmericanHeartAssociation,AmericanThoracicSociety,ArkansasMedicalSociety,NewYorkAcademyofMedicine,NewYorkAcademyofSciences,andSocietyforAcademicEmergencyMedicine


DavidFMBrown,MDAssociateProfessor,DivisionofEmergencyMedicine,HarvardMedicalSchoolViceChair,DepartmentofEmergencyMedicine,MassachusettsGeneralHospital

DavidFMBrown,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergencyPhysiciansandSocietyforAcademicEmergencyMedicine


WilliamKChiang,MDAssociateProfessor,DepartmentofEmergencyMedicine,NewYorkUniversitySchoolofMedicineChiefofService,DepartmentofEmergencyMedicine,BellevueHospitalCenter

WilliamKChiang,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofClinicalToxicology,AmericanCollegeofMedicalToxicology,andSocietyforAcademicEmergencyMedicine


AlfredCuschieri,MD,ChM,FRSE,FRCS,Head,Professor,DepartmentofSurgeryandMolecularOncology,UniversityofDundee,UK


ImadSDandan,MDConsultingSurgeon,DepartmentofSurgery,TraumaSection,ScrippsMemorialHospital

ImadSDandan,MDisamemberofthefollowingmedicalsocieties:AmericanAssociationfortheSurgeryofTrauma,AmericanCollegeofSurgeons,AmericanMedicalAssociation,AmericanTraumaSociety,CaliforniaMedicalAssociation,andSocietyofCriticalCareMedicine


DavidGreenwald,MDAssociateProfessorofClinicalMedicine,FellowshipProgramDirector,DepartmentofMedicine,DivisionofGastroenterology,MontefioreMedicalCenter,AlbertEinsteinCollegeofMedicine

DavidGreenwald,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,AmericanCollegeofGastroenterology,AmericanCollegeofPhysicians,AmericanGastroenterologicalAssociation,AmericanSocietyforGastrointestinalEndoscopy,andNewYorkSocietyforGastrointestinalEndoscopy


EugeneHardin,MD,FAAEM,FACEPFormerChairandAssociateProfessor,DepartmentofEmergencyMedicine,CharlesDrewUniversityofMedicineandScienceFormerChair,DepartmentofEmergencyMedicine,MartinLutherKingJr/DrewMedicalCenter


FayeMaryannLee,MDStaffPhysician,DepartmentofEmergencyMedicine,NewYorkUniversity/BellevueHospitalCenter

FayeMaryannLee,MDisamemberofthefollowingmedicalsocieties:PhiBetaKappa


SallySanten,MDProgramDirector,AssistantProfessor,DepartmentofEmergencyMedicine,VanderbiltUniversity

SallySanten,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergencyPhysiciansandSocietyforAcademicEmergencyMedicine


AssaadMSoweid,MD,FASGE,FACGAssociateProfessorofClinicalMedicine,EndosonographyandAdvancedTherapeuticEndoscopy,Director,EndoscopyBronchoscopyUnit,DivisionofGastroenterology,DepartmentofInternalMedicine,AmericanUniversityofBeirutMedicalCenter,Lebanon

AssaadMSoweid,MD,FASGE,FACGisamemberofthefollowingmedicalsocieties:AmericanCollegeofGastroenterology,AmericanCollegeofPhysicians,AmericanCollegeofPhysiciansAmericanSocietyofInternalMedicine,AmericanGynecologicalandObstetricalSociety,andAmericanMedicalAssociation


FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollegeofPharmacyEditorinChief,MedscapeDrugReference

Disclosure:MedscapeSalaryEmployment

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