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Ms Hampton is a 55-year-old female who presents to the emergency department with crampy epigastric pain that woke her up in the middle of the night. She has had similar attacks over the past several months that generally last for 3 to 4 hours. Heavy meals worsen the pain. She denies nausea and vomiting, has normal bowel movements, no fever or chills, and no hematuria, dysuria, or chest pain. Patient medical history is remarkable for type 2 DM, HTN, and lone atrial fibrillation. Medications include metoprolol, insulin, and aspirin; she occasionally takes acetaminophen for knee pain. She reports no alcohol use. On physical examination vitals are normal. The patient is afebrile. Sclera is nonicteric. Cardiac and lung examinations are normal except for the presence of an irregularly irregular cardiac rhythm. Abdominal examination shows a slightly obese abdomen. Bowel sounds are present. Abdomen is soft, with mild epigastric tenderness present. No guarding or rigidity is present. Murphy sign is negative. Rectal examination is normal. Stool is Hemoccult negative.

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1. What should be included in your DDX?

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Answer

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  1. Biliary colic

    • Peptic ulcer disease
    • Pancreatitis
    • Irritable bowel syndrome (IBS)
    • Mesenteric ischemia

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Biliary Colic

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The classic presentation of biliary colic is a deep, sharp, severe, gnawing episodic pain that is localized to the right upper quadrant (RUQ) or the epigastrium. It may radiate to the back and be associated with nausea and vomiting. Patients are pain-free in between the episodes. Biliary colic occurs when a gallstone becomes lodged in the cystic duct and the gallbladder contracts against the obstruction, in response to a fatty meal. Complications include acute cholecystitis, pancreatitis, and ascending cholangitis. A RUQ ultrasound is the diagnostic test of choice due to its high sensitivity and specificity. Cholecystectomy is recommended. Dissolution therapies (eg, ursodiol) are reserved for nonsurgical candidates.

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Alternative possible diagnoses include peptic ulcer disease (PUD), pancreatitis, IBS, ischemic bowel, mesenteric ischemia, and ischemic colitis.

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Peptic Ulcer Disease

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PUD presents with dull or hunger-like pain in the epigastrium that is either exacerbated or improved by food intake. Most ulcers are due to NSAID use, Helicobacter pylori infection, or both. Best predictors of PUD are a history of NSAID use and H. pylori infection. A significant number of patients with NSAID-induced ulcers do not experience pain. Anemia, GI bleeding, early satiety, or weight loss may be the only symptoms of PUD. Zollinger-Ellison syndrome is a rare cause of PUD. An esophagogastroduodenoscopy (EGD) should be considered with symptoms of significant bleeding, anemia, weight loss, early satiety, dysphagia, recurrent vomiting, a family history of GI cancer, or in patients who do not respond to initial therapy. Gastric ulcers always warrant biopsy to rule out adenocarcinoma. H. pylori testing should be done via the biopsied tissue.

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One can also test for H. pylori with a urea ...

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