Surgery

Acute RUQ abdominal pain

Aaron Safe on Jan 21, 2017

A 45-year-old woman presented to the Emergency Department with a 10-hour history of worsening right-upper-quadrant abdominal pain. During this time she has also experienced nausea, anorexia, and 2 episodes of vomitting. The patient reports she has had occasional episodes of RUQ pain previously, but they have previously been associated with eating and have never lasted more than an hour. She has a history of migraine headaches for which she takes Tylenol as needed. She also has a history of hypertension, though she has resisted her physicians advice to start an anti-hypertensive. Physical exam reveals guarding and RUQ tenderness, without rebound tenderness.

What one vital sign, if abnormal, would be most helpful in differentiating between the most likely diagnoses?

Expand all answers
Heart rate
Tachycardia is often a normal response to pain, so an elevated heart rate would be of little diagnostic value.


Respiratory rate
Abnormal respiratory rate would be of unclear diagnostic utility.


Temperature
Correct. Given the patients presentation and history, gall bladder pathology should be at the top of the differential. An abnormal temperature would help distinguish a non-infectious process process like symptomatic cholelithiasis, from an inflammatory/infectious process like acute cholecystitis or ascending cholangitis.


BMI
While obesity can be a risk factor for developing gall bladder stones, there would be little diagnostic value of an abnormal BMI.


The patients vitals are recorded. Suspecting gall bladder pathology, blood is drawn and sent for a CBC and liver enzymes.

  • Temperature: 102.1 F
  • Heart rate: 96 bpm
  • Blood Pressure: 150/85 mmHG
  • Respiratory rate: 14
  • spO2: 98%

 

 

 

 

CBC
20
13
39.4
250
Liver Enzymes
AST 55
ALT 61
Alk 450
Bilirubin (total) 1.8

In light of the patients vital signs and laboratory findings, what is the most likely diagnosis?

Expand all answers
Cholelithiasis
While this is a good guess, the presence of fever and markedly elevated WBC count makes another diagnosis more likely.


Acute cholecystitis
Correct. The combination RUQ pain, fever and marked leukocytosis is classic for acute cholecystitis.


Biliary colic
This pain is typically short-lived and associated with food consumption.


Ascending cholangitis
While this is a good guess, these patients are typically even sicker than our patient, with higher temperatures and more concerning overall clinical pictures. In addition they often experience jaundice and have very high temperatures. This patients bilirubin was normal with a moderate fever.


What element(s) of this patients history is/are strongly associated with the development of their current condition (check all that apply).

Select all that apply
Expand all answers
Tylenol use
There is no association between Tylenol use and acute cholecystitis.


Female
Correct. This is a risk factor for the development of gall bladder stones.


Uncontrolled hypertension
There is no association between hypertension and acute cholecystitis.


Previous episodes of abdominal pain
Correct. The patient's previous abdominal pains fit the description of biliary colic. A history of calculous biliary colic caries an increased risk for the development of acute cholecystitis.


What imaging test would be most likely to establish the diagnosis?

Expand all answers
Abdominal ultrasound
Correct. This is the most efficient study for the diagnosis of gallbladder disease.


Upright abdominal radiograph
While this would be useful to rule out a perforation that could introduce extraluminal air, the lack of rebound tenderness on exam makes perforation unlikely.


Abdominal CT
This could be a reasonable study if first-line diagnostics were inconclusive.


Barium swallow study
This would be more appropriate for a patient with a history of dysphagia.


What feature on ultrasound is LEAST likely to be seen in this patient?

Expand all answers
Thickening of the gallbladder wall.
This is a finding commonly seen in acute cholecystitis.


Presence of gallstones.
This is a finding commonly seen in acute cholecystitis.


Calcification within the gallbladder wall.
Correct. This is an uncommon manifestation of chronic cholecystitis, often referred to as "porcelain gallbladder". According to the history this is the first time our patient has had an episode like this, so it is unlikely that she would have developed intramural calcification. However, if present, this is an important finding as it incurs an increased risk of cancer.


Pericholecystic fluid.
This is a finding commonly seen in acute cholecystitis.


  • Ultrasound findings in acute cholecystitis

What would be the most appropriate choice of antibiotics for this particular patient?

Expand all answers
Meropenem
This would be appropriate in the case of healthcare-associated biliary infection where antibiotic resistance is a greater concern. There is no indication that our patients condition is healthcare-associated.


Ciprofloxacin + Metronidazole
This would be appropriate in the case of healthcare-associated biliary infection where antibiotic resistance is a greater concern. There is no indication that our patients condition is healthcare-associated.


Cefazolin
Correct. This would cover organisms responsible for most cases of community-acquired cholecystitis, including E. coli and Enterococcus (UpToDate.com, "Treatment of acute calculous cholecystitis").


Piperacillin-tazobactam
This would be appropriate in the case of healthcare-associated biliary infection where antibiotic resistance is a greater concern. There is no indication that our patients condition is healthcare-associated.


If a patient with acute cholecystitis is deemed not to be a surgical candidate, percutaneous cholecystostomy may performed. Which of the following statements about the role of percutaneous cholecystostomy is NOT true:

Expand all answers
Percutaneous cholecystostomy is typically used as a temporizing measure, with the goal of a delayed cholecystectomy at a later date.
Percutaneous cholecystostomy decompresses the gall bladder and allows purulent material to drain away from the obstruction.
Percutaneous cholecystostomy resolves acute cholecystitis in approximately 50% of patients.
Percutaneous cholecystostomy is actually quite effective, resolving acute cholecystitis in approximately 90% of patients (UpToDate.com, "Treatment of acute calculous cholecystitis").


Indications for percutaneous cholecystostomy include severe cholecystitis, late presentation (>72 hours after symptoms), and contraindications to general anesthesia.

Failure to properly recognize and treat acute cholecystitis can lead serious complications, including (check all that apply):

Select all that apply
Expand all answers
Gangrenous cholecystitis
Perforation of gallbladder
Emphysematous cholecystitis
Empyema of gallbladder

A 45-year-old woman presented to the Emergency Department with a 10-hour history of worsening right-upper-quadrant abdominal pain. During this time she has also experienced nausea, anorexia, and 2 episodes of vomitting. The patient reports she has had occasional episodes of RUQ pain previously, but they have previously been associated with eating and have never lasted more than an hour. She has a history of migraine headaches for which she takes Tylenol as needed. She also has a history of hypertension, though she has resisted her physicians advice to start an anti-hypertensive. Physical exam reveals guarding and RUQ tenderness, without rebound tenderness.

What one vital sign, if abnormal, would be most helpful in differentiating between the most likely diagnoses?

Expand all answers
Heart rate
Tachycardia is often a normal response to pain, so an elevated heart rate would be of little diagnostic value.


Respiratory rate
Abnormal respiratory rate would be of unclear diagnostic utility.


Temperature
Correct. Given the patients presentation and history, gall bladder pathology should be at the top of the differential. An abnormal temperature would help distinguish a non-infectious process process like symptomatic cholelithiasis, from an inflammatory/infectious process like acute cholecystitis or ascending cholangitis.


BMI
While obesity can be a risk factor for developing gall bladder stones, there would be little diagnostic value of an abnormal BMI.


The patients vitals are recorded. Suspecting gall bladder pathology, blood is drawn and sent for a CBC and liver enzymes.

  • Temperature: 102.1 F
  • Heart rate: 96 bpm
  • Blood Pressure: 150/85 mmHG
  • Respiratory rate: 14
  • spO2: 98%

 

 

 

 

CBC
20
13
39.4
250
Liver Enzymes
AST 55
ALT 61
Alk 450
Bilirubin (total) 1.8

In light of the patients vital signs and laboratory findings, what is the most likely diagnosis?

Expand all answers
Cholelithiasis
While this is a good guess, the presence of fever and markedly elevated WBC count makes another diagnosis more likely.


Acute cholecystitis
Correct. The combination RUQ pain, fever and marked leukocytosis is classic for acute cholecystitis.


Biliary colic
This pain is typically short-lived and associated with food consumption.


Ascending cholangitis
While this is a good guess, these patients are typically even sicker than our patient, with higher temperatures and more concerning overall clinical pictures. In addition they often experience jaundice and have very high temperatures. This patients bilirubin was normal with a moderate fever.


What element(s) of this patients history is/are strongly associated with the development of their current condition (check all that apply).

Select all that apply
Expand all answers
Tylenol use
There is no association between Tylenol use and acute cholecystitis.


Female
Correct. This is a risk factor for the development of gall bladder stones.


Uncontrolled hypertension
There is no association between hypertension and acute cholecystitis.


Previous episodes of abdominal pain
Correct. The patient's previous abdominal pains fit the description of biliary colic. A history of calculous biliary colic caries an increased risk for the development of acute cholecystitis.


What imaging test would be most likely to establish the diagnosis?

Expand all answers
Abdominal ultrasound
Correct. This is the most efficient study for the diagnosis of gallbladder disease.


Upright abdominal radiograph
While this would be useful to rule out a perforation that could introduce extraluminal air, the lack of rebound tenderness on exam makes perforation unlikely.


Abdominal CT
This could be a reasonable study if first-line diagnostics were inconclusive.


Barium swallow study
This would be more appropriate for a patient with a history of dysphagia.


What feature on ultrasound is LEAST likely to be seen in this patient?

Expand all answers
Thickening of the gallbladder wall.
This is a finding commonly seen in acute cholecystitis.


Presence of gallstones.
This is a finding commonly seen in acute cholecystitis.


Calcification within the gallbladder wall.
Correct. This is an uncommon manifestation of chronic cholecystitis, often referred to as "porcelain gallbladder". According to the history this is the first time our patient has had an episode like this, so it is unlikely that she would have developed intramural calcification. However, if present, this is an important finding as it incurs an increased risk of cancer.


Pericholecystic fluid.
This is a finding commonly seen in acute cholecystitis.


  • Ultrasound findings in acute cholecystitis

What would be the most appropriate choice of antibiotics for this particular patient?

Expand all answers
Meropenem
This would be appropriate in the case of healthcare-associated biliary infection where antibiotic resistance is a greater concern. There is no indication that our patients condition is healthcare-associated.


Ciprofloxacin + Metronidazole
This would be appropriate in the case of healthcare-associated biliary infection where antibiotic resistance is a greater concern. There is no indication that our patients condition is healthcare-associated.


Cefazolin
Correct. This would cover organisms responsible for most cases of community-acquired cholecystitis, including E. coli and Enterococcus (UpToDate.com, "Treatment of acute calculous cholecystitis").


Piperacillin-tazobactam
This would be appropriate in the case of healthcare-associated biliary infection where antibiotic resistance is a greater concern. There is no indication that our patients condition is healthcare-associated.


If a patient with acute cholecystitis is deemed not to be a surgical candidate, percutaneous cholecystostomy may performed. Which of the following statements about the role of percutaneous cholecystostomy is NOT true:

Expand all answers
Percutaneous cholecystostomy is typically used as a temporizing measure, with the goal of a delayed cholecystectomy at a later date.
Percutaneous cholecystostomy decompresses the gall bladder and allows purulent material to drain away from the obstruction.
Percutaneous cholecystostomy resolves acute cholecystitis in approximately 50% of patients.
Percutaneous cholecystostomy is actually quite effective, resolving acute cholecystitis in approximately 90% of patients (UpToDate.com, "Treatment of acute calculous cholecystitis").


Indications for percutaneous cholecystostomy include severe cholecystitis, late presentation (>72 hours after symptoms), and contraindications to general anesthesia.

Failure to properly recognize and treat acute cholecystitis can lead serious complications, including (check all that apply):

Select all that apply
Expand all answers
Gangrenous cholecystitis
Perforation of gallbladder
Emphysematous cholecystitis
Empyema of gallbladder

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