Tuesday, February 3, 2015

A 46 Year Old Woman With Acute Severe Right Upper Abdominal Pain

A 46 year old woman presents to the emergency department with the complaint of significant right upper quadrant abdominal pain that started about 10 hours ago. She says the pain has been fairly continuous during this time and the pain radiates to her back. She remembers experiencing a much milder form of this pain previously that typically occurred following heavy fatty meals and would last for an hour or so. The current episode is very severe, associated with vomiting and mild fever. She denies any chest pain, heart burn or any history of recent weight loss.

Physical Examination:

  • An obese woman in discomfort due to pain. 
  • Abdominal tenderness with voluntary guarding to palpation of the right upper quadrant and is unable to breathe inwards during palpation. 
  • she has fullness in her right upper quadrant but it is difficult to detect any organomegaly because of her obese body. 
  • She is not jaundiced.
  • Bowel sounds are mildly hypoactive.
  • All other systems are normal on examination.
  • She had a mild temperature of 100.1 F
The Patient was taken in for an ultrasound of her abdomen and it shows the following findings:

Ultrasound findings above show gallstone shadows, gall bladder wall thickening and a pericholecystic fluid . These findings as well as the history and examination are pointing to the diagnosis of.........

Acute Cholecystitis. 

Case Discussion:
Acute cholecystitis is an acute inflammation of the gall bladder most commonly due to obstruction of the cystic duct by gallstones. 
Less common causes are conditions that may lead to biliary stasis for example trauma, sepsis, total parenteral nutrition. 

Clinical History: patients present with:
  • Right upper quadrant abdominal pain.
  • the pain radiates to the back and the right shoulder.
  • The pain is continuous lasting more than 6 hours
  • nausea and vomiting
On Physical Examination: findings may include:
  • Right upper quadrant tenderness
  • fever
  • sometimes a palpable gallbladder
  • Murphy's sign ( inability to inspire during right upper quadrant palpation due to pain)
Diagnosis: is made by clinical history and examination and is supported by the lab work which shows:
  • Increased WBC count
  • increased billirubin (total and direct)
  • Increased alkaline phospahtase
  • CT scan or MRi may show  gall bladder thickening and pericholecystic fluid.
  • Ultrasound is a quick diagnostic imaging that helps in detecting gall stones, sludge, gall bladder wall thickening and pericholecystic fluid. 
  • A HIDA scan will detect cystic duct obstruction by demonstrating impaired gall bladder filing
1. Patients should be properly hydrated with IV fluids, given analgesics and should avoid taking anything by mouth following the diagnosis. . 
2. Antibiotics ( e.g B lactums or cephalosporins ) are started to prevent the onset of worsening ductal infection. 
3. open or laproscopic cholecytectomy is the definitive treatment. 

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