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Mrs Hampton's history suggests biliary colic. A RUQ ultrasound reveals multiple small gallstones. CBC is normal. Serum lipase and liver enzymes were normal. Urea breath test for H. pylori was negative. After surgical consultation, cholecystectomy was planned in the next few weeks. Unfortunately, Mrs Hampton returned to the emergency department prior to scheduled surgery with constant pain in her RUQ associated with fever and chills. She looks in acute distress. She reports dark urine. Vitals are stable except for the presence of fever at 38.3°C. Sclera was anicteric. Abdominal examination reveals RUQ tenderness with positive Murphy sign.

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1. What should be included in your DDX?

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Answer

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  1. Common bile duct (CBD) obstruction (also known as choledocholithiasis)

    • Ascending cholangitis
    • Acute cholecystitis
    • Hepatitis

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Choledocholithiasis and Ascending Cholangitis

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The classic presentation is RUQ pain, fever, and jaundice, also known as Charcot triad. This occurs due to CBD obstruction, most commonly from a gallstone. Complications include obstruction, jaundice, fever, leukocytosis, sepsis, and pancreatitis. ERCP is both diagnostic and therapeutic. It is the preferred test of choice in patients with a high pretest probability of CBD stone with obstruction. It allows direct cannulation of CBD and relieves obstruction via simultaneous stone extraction and sphincterotomy. In patients who are less likely to have a CBD stone, a less invasive test such as magnetic resonance cholangiopancreatography (MRCP) or endoscopic ultrasound (EUS) would be appropriate as an initial study. Treatment includes IV hydration, IV broad-spectrum antibiotics, decompression of the biliary system (via ERCP in patients with persistent pain, hypotension, altered mental status, persistent high fever, WBC ≥20,000, bilirubin >10 mg/dL) and electively in more stable patients, and/or cholecystectomy.

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Alternative diagnoses to consider include acute cholecystitis and acute hepatitis.

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Acute Cholecystitis

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Acute cholecystitis presents as persistent RUQ or epigastric pain associated with fever, nausea, and vomiting. Murphy sign may be present (sensitivity 65% and specificity 87%). Acute cholecystitis is caused by persistent obstruction of the cystic duct with stones resulting in gallbladder inflammation and pain. It may be complicated with necrosis, infection, and gangrene. The test of choice is a RUQ ultrasound. Cholescinitigraphy (HIDA scan) is useful when the pretest probability is high and ultrasound is nondiagnostic. Nonvisualization of the gallbladder suggests cystic duct obstruction and is highly specific for acute cholecystitis. Treatment includes IV hydration and IV antibiotics.

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Acute Hepatitis

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Viral or alcoholic hepatitis should be considered in a patient presenting with abdominal pain, jaundice, anorexia, nausea, malaise, hepatomegaly, or hepatic tenderness. Liver enzymes are very high in acute hepatitis. If suspected, appropriate serologies should be ordered.

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Abdominal Pain

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Abdominal pain is one of the most common causes for hospital admission in the United States. It is caused by conditions that range from trivial to life-threatening.

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