Diagnosis
History and physical
Symptomatic cholelithiasis
RUQ pain radiating around right back after fatty meals, resolves after a few hours, female, multigravida, obese
Acute cholangitis
Persistent RUQ pain, fever, jaundice (Charcot’s triad)
Acute cholecystitis
Persistent (>4 h), severe RUQ pain, fever, Murphy’s sign
Acute pancreatitis
Severe epigastric pain radiating straight through to back (2o cholelithiasis, alcohol abuse)
Acute gastritis
Aspirin, NSAIDa use, steroid use, gnawing epigastric pain
Peptic ulcer disease
Intermittent burning epigastric pain that improves (duodenal ulcer) or worsens (gastric ulcer) with food intake (2o H. pylori infection, NSAID, steroid use)
Malignancy (gastric, pancreatic, biliary)
Chronic pain, weight loss, fatigue
Fitz-Hugh-Curtis syndrome
RUQ pain, history of recent pelvic inflammatory disease (either Chlamydia trachomatis or Neisseria gonorrhoeae), fever, “violin string” adhesions between liver and diaphragm
Myocardial infarction
Epigastric pain (referred pain), diabetes, cardiovascular disease, hypercholesterolemia
Acute hepatitis
Hepatitis A (recent foreign travel, IVDA, raw shellfish, fecal-oral)
Hepatic abscess
RUQ pain, high fever, hepatomegaly (bacterial or amoebic)
Acute pyelonephritis
Costovertebral angle tenderness, dysuria, hematuria
What Is the Most Likely Diagnosis?
With her current history of severe persistent abdominal pain following ingestion of fatty foods, nausea and vomiting, and associated right upper quadrant tenderness to palpation, the etiology is most likely of biliary origin. The patient’s prior history is consistent with symptomatic cholelithiasis. With a positive Murphy’s sign, fever, tachycardia, and elevated WBC count, the most likely current diagnosis is acute cholecystitis. With a normal total bilirubin and alkaline phosphatase, acute cholangitis and choledocholithiasis are less likely. Similarly, a normal amylase and lipase rule out gallstone pancreatitis.
History and Physical
Why Is the Term Biliary Colic a Misnomer? What Is a Better Term?
Colicky pain typically waxes and wanes, with periods of intense pain (such as from a ureter intermittently contracting in the presence of a stone) followed by relief. The pain from gallstones is constant, may last from minutes to hours, and then dissipates. A better term is symptomatic cholelithiasis.
What Are the Main Risk Factors for Developing Cholesterol Gallstones?
Female gender, pregnancy, oral contraceptive use (excess estrogen leads to higher cholesterol in bile and decreased gallbladder motility) as opposed to obesity (decreases bile salts), high-fat diet (increases bile cholesterol), hereditary (higher incidence in Hispanics, Pima Indians), Crohn’s disease and terminal ileal resection (loss of bile salts), and rapid weight loss after gastric surgery (impaired gallbladder emptying).
Patients with biliary disease often have the 4 “Fs” (female, fat, forty, fertile)
Why Is It Important to Distinguish Between Symptomatic Cholelithiasis and Acute Cholecystitis?
Symptomatic cholelithiasis is usually managed as an outpatient, with eventual elective laparoscopic cholecystectomy. Acute cholecystitis requires hospital admission, intravenous (IV) antibiotics, and urgent cholecystectomy.
What Is the Difference Between an Urgent and Emergent Case?
An urgent case can be booked during the next available operating room (OR) time slot, while an emergent case requires a patient to be rushed to the OR immediately.
How does one Clinically distinguish between Symptomatic Cholelithiasis and Acute Cholecystitis?
Symptomatic cholelithiasis | Acute cholecystitis | |
---|---|---|
History | RUQ pain usually resolves within minutes to 3–4 h | Unremitting RUQ pain >6 h, associated nausea/vomiting |
Physical exam | Mild RUQ tenderness to palpation | Murphy’s sign |
Vital signs | Normal | Fever, tachycardia |
Laboratory values | Normal WBC | Elevated WBC with left shift |
Ultrasound findings | Gallstones | Gallstones, gallbladder wall thickening > 4 mm, pericholecystic fluid, sonographic Murphy’s sign |
Pathophysiology
What Is the Significance of Abdominal Pain After Eating Fatty Foods?
It suggests a biliary origin of the pain. Fatty food ingestion triggers the release of cholecystokinin, which leads to contraction of the gallbladder. Gallstones may obstruct the cystic duct so that the gallbladder is unable to empty bile as it attempts to contract after fatty food ingestion. The ensuing distention of the gallbladder stretches the visceral peritoneum that surrounds it, leading to RUQ and/or epigastric pain that is vague and mild to moderate in severity (symptomatic cholelithiasis).
What Is the Significance of RUQ Pain Combined with Scapular Pain?
The gallbladder and the scapula share the same cutaneous dermatome from the same spinal cord levels. The scapula receives cutaneous innervation from the supraclavicular nerves. Since the same spinothalamic pathways (pain and temperature) are activated, gallbladder distention/inflammation triggers scapular pain via the phrenic nerve.
What Is the Significance of the Patient’s Inspiration Stopping with RUQ Palpation?
This physical examination finding is called Murphy’s sign and is thought to be specific to acute cholecystitis. It represents focal peritonitis of the anterior abdominal wall parietal peritoneum due to inflammation of the adjacent gallbladder. When the patient inspires, the diaphragm moves caudad, as does the gallbladder. Palpating deep in the RUQ causes the gallbladder to then come into contact with the parietal peritoneum, further irritating the inflamed parietal peritoneum and causing cessation of inspiration secondary to pain.
Watch Out
Do not confuse Murphy’s sign with McMurray’s sign, which is a palpable or audible snap occurring when extending a fully flexed knee while applying tibial torsion. A positive McMurray’s sign indicates a medial meniscal tear.
What Is the Difference Between Somatic and Visceral Pain?
Somatic pain is well localized and typically secondary to peritoneal irritation. Patients can often point to where it hurts. In contrast, visceral pain is more difficult to localize and results from mechanical stretching of the abdominal (visceral) organs.
What Is the Clinical Significance of the Patient’s Low-Grade Fever and Tachycardia?
The presence of systemic signs of infection, such as fever and tachycardia, suggests a more severe biliary disease such as acute cholecystitis or acute cholangitis. Symptomatic cholelithiasis (biliary colic) does not present with systemic symptoms.
What Is Chronic Cholecystitis?
Recurrent bouts of symptomatic cholelithiasis often lead to chronic inflammation of the gallbladder with fibrotic changes seen on histologic examination. As such, biliary colic, symptomatic cholelithiasis, and chronic cholecystitis are interchangeable terms.
What Exactly Causes Acute Cholecystitis?
Acute cholecystitis is caused by sustained obstruction (impaction) of the cystic duct, most often by a gallstone. This obstruction leads to inflammation and edema of the gallbladder wall and then eventually bacterial overgrowth and invasion of the gallbladder wall. This can progress to ischemia and necrosis (gangrenous cholecystitis) and rarely gallbladder perforation.
What Are the Typical Organisms in the Bile?
The most common organisms found in biliary cultures from patients with acute cholecystitis are Escherichia coli, Bacteroides fragilis, Klebsiella, Enterobacter, Enterococcus, and Pseudomonas species.
What Are the Components of Bile?
The three main components of bile are bile salts, cholesterol, and lecithin (a phospholipid). Bile also contains water, electrolytes, proteins, and bile pigments.
What Are the Two Main Types of Gallstones?
The two main types of gallstones are cholesterol (70–80 % of gallstones in the USA) and pigment.
How Do Cholesterol Gallstones Form?
Cholesterol gallstones form when the concentration of cholesterol in the bile exceeds its solubility, which causes precipitation of cholesterol crystals. The solubility of cholesterol is dependent on the concentration of cholesterol, bile salts, and lecithin in the bile. Lower concentrations of bile salts or lecithin favor precipitation of cholesterol, as does high levels of cholesterol.
How Do Pigmented Gallstones Form?
These stones comprise the remaining 20–30 % of gallstones seen in the USA. Pigmented stones are classified as black or brown and contain less than 30 % cholesterol. The dark coloration is a result of the presence of calcium bilirubinate within the stones. Black stones are often associated with hemolytic disease such as hereditary spherocytosis or sickle cell disease. As a result of the breakdown of red blood cells, the amount of unconjugated bilirubin increases, leading to the formation of black stones. Black stones are most often found within the gallbladder. Brown stones, in comparison, most often form within the bile ducts. They are larger and softer than black stones and usually are associated with bacterial infection and parasites. They are more common in Asian countries.
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