Ch. 15 Postprandial RUQ Pain

Question 1

What is her most likely dx?

Answer 1

WIth her current hx of severe persistent abdominal pain following ingestion of fatty foods, nausea and vomiting, and associated RUQ tenderness to palpation, the etiology is most likely of biliary origin.

The pt’s prior hx is consistent with symptomatic cholelithiasis. With a positive Murphy’s sign, fever, tachycardia, and elevated WBC count, the most likely current dx is acute cholecystitis.

With a normal tbili and AP, acute cholangitis and choledocholithiasis are less likely.

A normal amylase and lipase r/o gallstone pancreatitis.

Question 2

What is the differential dx?

Answer 2

Question 3

Why is the term biliary colic a misnomer? What is a better term?

Answer 3

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.

Question 4

What are the main risk factors for developing cholesterol gallstones?

Answer 4

4 “Fs” = female, fat (decreases bile salts), forty, fertile

OCP use (excess estrogen leads to higher cholesterol in bile and decreased gallbladder motility)

Hereditary (higher incidence in Hispanics, Pima Indians)

Crohn’s Disease and terminal ileal resection (loss of bile salts)

Question 5

Why is it important to distinguish between symptomatic cholelithiasis (biliary colic) and acute cholecystitis?

How does one clinically distinguish between the two?

(Hx, PE, VS, Lab, US findings)

Answer 5

Symptomatic cholelithiasis = usually managed as an outpatient, wih eventual elective lap cholecystectomy

Acute cholecystitis = requires hospital admission, IV abx, urgent cholecystectomy

Question 6

What is the significance of abdominal pain after eating fatty foods?

What is the pathophysiology?

Answer 6

Suggests biliary origin of pain

Fatty food ingestion triggers CCK release –> contraction of gallbladder –> gallstones may obstruct cystic duct so that gallbladder is unable to empty bile as it attempts to contract after fatty food ingestion

The ensuing distension of the gallbladder stretches the visceral peritoneum that surrounds it –> RUQ and/or vague moderate-severe epigastric pain (symptomatic cholelithiasis)

Question 7

What is the significant of RUQ pain combined with scapular pain?

Answer 7

Gallbladder + scapula share the same cutaneous dermatome from the same spinal cord levels

Scapula receives cutaneous innervation from supraclavicular nerves. Since the same spinothalamic pathways (pain and temperature) are activated, gallbladder distension/inflammation triggers scapular pain via phrenic nerve

Question 8

What is the significance of the patient’s inspiration stopping with RUQ palpation?

Answer 8

Murphy’s Sign = specific to acute cholecystitis

Represents focal peritonitis of the anterior abdominal wall parietal peritoneum due to inflammation of the adjacent gallbladder

When the pt 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 inflammed parietal peritoneum –> causing cessation of inspiration 2/2 pain

Question 9

What is the difference between somatic and visceral pain?

Answer 9

Somatic = well localized and typically 2/2 peritoneal irritation (pts can point to where it hurts)

Visceral = more difficult to localize and results from mechanical stretching of the abdominal (visceral) organs

Question 10

What is chronic cholecystitis?

Answer 10

Recurrent bouts of symptomatic cholelithiasis –> chronic inflammation of gallbladder with fibrotic changes seen on histo exam

Question 11

What causes acute cholecystitis?

What are the typical organisms in the bile?

Answer 11

Cause: sustained obstruction (impaction) of the cystic duct, most often by a gallstone –> obstruction leads to inflammation + edema of gallbladder wall –> eventual bacterial overgrowth + invasion of gallbladder wall

–> progress to ischemia + necrosis (gangrenous cholecystitis) –> rarely perforation

Most common organisms found in biliary cultures from acute cholecystitis pts:

• E. coli
• Bacteroides fragilis
• Klebsiella
• Enterobacter
• Enterococcus
• Pseudomonas

Question 12

What are the components of bile? (3)

Answer 12

Three main components:

bile salts, cholesterol, lecithin (phospholipid)

Question 13

What are the different manifestations of gallstone disease? (7)

Answer 13

Question 14

What is the diagnostic test of choice?

Answer 14

RUQ U/S

Question 15

What is the normal CBD diameter, and what is the implication of a dilated CBD?

Answer 15

Normal CBD ranges from 4 to 5 mm

Normal diameter increases slightly with age (approximately 1 mm per decade after age 40)

In most patients, a CBD > 6 mm is considered abnormally dilated –> suggests obstruction from either a gallstone or a tumor

Question 16

What if the U/S demonstrates gas bubbles in the gallbladder wall?

Answer 16

emphysematous cholecystitis

This occurs when the gallbladder becomes infected with gas-forming organisms (e.g., clostridium)

Dx more common in older men, often with DM

Can progress to gallbladder perforation, intra-abdominal abscess, sepsis, and death if cholecystectomy not performed emergently

Question 17

What is pneumobilia?

Answer 17

Air in the biliary tree 2/2 gallstone ileus (due to a fistula between the gallbladder and duodenum)

Question 18

What if acute cholecystitis is suspected but the u/s does not demonstrate gallstones?

What is a better test to use?

Answer 18

Possibilities:

• Rare false-negative U/S (<5%)
• Acalculous cholecystitis - most often occurs in critically ill pts
  
  • 2/2 combination of biliary stasis and gallbladder ischemia in presence of severe systemic illness
    
    • Long-term TPN 2/2 biliary sludging

Test of choice: HIDA scan

Question 19

Mgmt:

The patient presented has an U/S demonstrating gallstones, pericholecystic fluid, gallbladder wall thickening of 5 mm, and a positive sonographic Murphy’s sign. What is the next step in the mgmt of this pt?

Answer 19

Pts with acute cholecystitis should be:

• Admitted to hosp
• made NPO
• given IV fluids
• given IV abx with gram-negative and anaerobic coverage

Lap chole should be performed, ideally within 48 hrs.

Question 20

Failure to recognize Cholangitis

Answer 20

Charcot’s triad:

• RUQ pain
• Jaundice
• Fever

Reynolds pentad

• Charcot’s triad + hypotension + AMS

Mgmt: Immediate decompression of biliary tract, most often with ERCP

Question 21

Mgmt:

• Asymptomatic gallstones
• Symptomatic cholelithiasis (biliary colic)
• Acute cholecystitis
• Acute acalculous cholecystitis
• Emphysematous cholecystitis
• Gallstone ileus

Answer 21

Mgmt:

• Asymptomatic gallstones: cholecystectomy not indicated
• Symptomatic cholelithiasis (biliary colic): elective lap chole
• Acute cholecystitis: urgent (within 48 h) lap chole
• Acute acalculous cholecystitis: cholecystostomy tube if critically ill
• Emphysematous cholecystitis: emergent chole
• Gallstone ileus: remove large impacted gallstone from terminal ileum (leave gallbladder alone)

Question 22

A 23 year old, overweight, black woman with a history of hemolytic anemia presents to the emergency department with fever and right upper quadrant pain. A right upper quadrant ultrasound is performed which demonstrates gallstones, a thickened gallbladder wall, and pericholecystic fluid.

Which patient characteristic puts her at highest risk of developing acute cholecystitis?

a. Obesity
b. Ethnicity
c. Young age
d. Patients with hemolytic anemia
e. Female sex

Answer 22

e. Female Sex

Compared to males, females have a 3:1 risk ratio. Having a first degree relative with a history of acute cholecystitis increases risk by a 2:1 ratio. Other factors that increase patient’s risk are a history of hemolytic anemia, terminal ileal disease, type IV hypercholesterolemia, native American ethnicity, and diabetes mellitus.

Question 23

A patient presents to the emergency department complaining of severe abdominal pain and fevers 4 days after an elective cholecystectomy. A right upper quadrant ultrasound is obtained which shows mild fluid in morrisons pouch (Hepatorenal recess of subhepatic space). An acute abdominal series shows no free air or dilated bowel. What is the best next diagnostic test?

a. Diagnostic laparoscopy.
b. ERCP
c. CT scan
d. MRCP
e. HIDA scan

Answer 23

e. HIDA scan

The differential diagnosis for abdominal pain after cholecystectomy includes bleeding, bile leak, missed enterotomy, and common bile duct injury. A CT scan, like an ultrasound, on post-op day 4 will likely show fluid but won’t help determine the source of the fluid. An ERCP is an invasive procedure that can be used to treat bile leaks but is not the best diagnostic test. MRCP may diagnose a ductal injury or a fluid collection but not the source. The HIDA scan will help to rule out a bile leak, clip across the duct, or a duct injury. Further studies can be ordered based on the results of the HIDA scan.

Question 24

A 70 year old female is seen in the emergency department and diagnosed with acute cholecystitis. She is being brought to the operating room for a laparoscopic cholecystectomy. What would be the most appropriate antimicrobial prophylaxis to prevent surgical site infection?

a. Pipercillin-tazobactam
b. Cefazolin
c. Ampicillin-sulbactam
d. None needed
e. Vancomycin

Answer 24

b. Cefazolin

Patients undergoing laparoscopic cholecystectomy for acute cholecystectomy are at higher risk for infectious complications than patients being operated on electively. Perioperative antibiotics should be administered that have good coverage of enteric gram-negative bacilli, enterococcus and clostridia species. There is significant resistance to ampicillin-sulbactam and fluoroquinolones. Vancomycin has poor coverage of gram negatives. Pipercillin-tazobactam has broad spectrum activity but should be reserved for severe infections.