Chronic Upper Abdominal Pain
A 65-year-old female with chronic non-specific abdominal pain develops acute severe pain in her epigastrium. She presents to the ED for evaluation.Â
What's on the differential diagnosis?
Perforated hollow viscus
Gastritis
Peptic ulcer disease
Pancreatitis
Biliary pathology- cholecystitis, choledocholithiasis, hepatitis
Pneumonia
Myocardial ischemia
What are the relevant clinical questions and what is included in a focused physical exam?
Further details about the abdominal pain- prior similar episodes, onset/ duration, aggravating/ alleviating factors, constant or intermittent, radiating pain, severity, quality of pain (burning, stabbing, cramps).
Associated symptoms- systemic symptoms. Fevers/ chills. Nausea/ vomiting.
Change in color of urine or stool?
Any prior medical or surgical history? Any medications? Smoker?
Exam- abdominal palpation- identify tenderness and presence of peritonitis.
The pain is stabbing and constant, and she's never had this pain before. She occasionally has right shoulder pain. She reports nausea and loss of appetite, but denies fevers/ chills/ vomiting. She had tea-colored urine and pale white stool a couple days ago. She has no medical or surgical history and is a non-smoker.
On exam, she is afebrile, heart rate in the 90s. She is tender in the right upper quadrant with minimal palpation.
What is the initial diagnostic workup?
Labs: CBC, amylase/ lipase, hepatic enzymes, bilirubin
Right upper quadrant ultrasound
Possible computed tomography
What ultrasound findings are consistent with cholelithiasis?
Masses in the gallbladder that are echogenic (reflect on the anterior surface) with a posterior shadow and mobile/ dependent (move with changes in patient position).
What ultrasound findings are consistent with acute calculous cholecystitis?
Gallstones + gallbladder wall thickening + pericholecystic fluid +/- positive sonographic Murphys sign.
What radiographic and laboratory findings are consistent with choledocholithiasis?
Dilated common bile duct, stones visualized in the common bile duct, elevated bilirubin.
What clinical/ radiologic/ laboratory findings are consistent with acute calculous cholecystitis?
Criteria are based on Tokyo guidelines.[1]
Local signs of inflammation- Murphy’s sign, RUQ mass/pain/tenderness
Systemic signs of inflammation- fever, elevated CRP, elevated WBC count
Imaging findings characteristic of acute cholecystitis
Suspected diagnosis- one local sign + one systemic sign
Definite diagnosis- one local sign + one systemic sign + imaging findings
An ultrasound reveals gallstones, gallbladder wall thickening, and a dilated common bile duct. Her bilirubin is 2.
Diagnosis?
Cholecystitis with high risk for choledocholithiasis.
Right Upper Quadrant Ultrasound- Gallstones
Case courtesy of Maulik S Patel, Radiopaedia.org. From the case rID: 20542
Right Upper Quadrant Ultrasound- Gallbladder Wall Thickening
Case courtesy of RMH Core Conditions, Radiopaedia.org. From the case rID: 3802
Patient was taken to the OR and underwent uncomplicated laparoscopic cholecystectomy. Intraoperative cholangiogram revealed multiple stones in the distal common bile duct. Despite multiple attempts, stone retrieval was unsuccessful. She underwent a postoperative endoscopic retrograde cholangiopancreatography (ERCP) with successful stone extraction.
SAGES Guidelines on Diagnosis and Management of Choledocholithiasis
Cholelithiasis, Predicting Likelihood of Choledocholithiasis
Choledocholithiasis Management Algorithm
Evaluation and Management of Acute Cholecystitis
Diagnosis
History- right upper quadrant/ epigastric pain, nausea/ vomiting.
Labs- CBC, renal panel, LFTs.
Radiology- right upper quadrant ultrasound.
          - Cholelithiasis: echogenic masses in the gallbladder with a posterior shadow that are mobile (move with changes in patient position).
          - Acute calculous cholecystitis: gallstones + gallbladder wall thickening + pericholecystic fluid +/- positive sonographic Murphys sign.
Diagnostic Criteria for Acute Cholecystitis- Tokyo 2018 Guidelines[1]
Local signs of inflammation- Murphy’s sign, RUQ mass/pain/tenderness
Systemic signs of inflammation- fever, elevated CRP, elevated WBC count
Imaging findings characteristic of acute cholecystitis
Suspected diagnosis- one local sign + one systemic sign
Definite diagnosis- one local sign + one systemic sign + imaging findings
Management
Cholecystitis is managed with early laparoscopic cholecystectomy unless the patient is too ill to tolerate surgery.[2] A percutaneous cholecystostomy is a minimally-invasive option for high-risk patients, avoiding the risk of general anesthesia. However, in a recent study of high-risk patients, cholecystectomy was associated with fewer complications than percutaneous cholecystostomy.[3]Â
Evaluation and Management of CholedocholithiasisÂ
Diagnosis- dilated common bile duct, stones visualized in the common bile duct, elevated bilirubin.
Management- common bile duct stones are managed with endoscopic or operative stone extraction.[4,5]
References