Chief Complaint: “I have pain in my stomach” x 12 hours
Case: Joanna is a 42 y/o female that presents to the ED with abdominal pain.
- No recent travel history (last was 5 months ago to California)
- No recent infections or sick eposure
- Has been having episodes of heart burn a few times a month usually after eating late at night. Antacids relieve symptoms usually.
- Location: Points to middle and upper right abdomen
- Precipitating events: Pain started after having dinner yesterday
- Intensity: 8/10
- Onset: 12 hours ago
- Quality of pain: Dull
- Duration: constant
- Character: worsening pain
- Previous episodes: Has had mild pain after meals that usually goes away. Has never had this pain before.
- Radiation: It radiates to the back and to the right shoulder.
- Aggravating factors: Moving and laying in supine position
- Alleviating factors: Feels better sitting in a hunched over position or laying on the side.
- Other sxs: feel nauseaus after dinner, feels may have fever, and vomited 2 times (food and yellow vomitus but no blood) the night before.
- No hospitalizations
- Antacids at night for heart burn
- NKDA, food or environmental allergies
Past surgical hx: None
- Mother: Alive, hx of gallstones
- Father: Deceased at 68 from stroke.
- Brother: Alive, pmhx unknown.
- Married and lives with husband and 3 children.
- Works at a hospital as a HR manager
- Admits to alcohol consumption of 2 glasses of wine with dinner 2x, a week but this week had 3 glass of wine each night over the past 3 days.
- Denies use of illcit substances
- Denies ever smoking
- Does not exercise because she feels she is too busy.
- She usually eats a lot of fast food for lunch and dinner because of how busy she is at work. Her husband helps prepare the kids meals.
- Gen: complains of mild fatigue but from playing with children. No unitentional weight loss.
- Skin: No jaundice. No rashes.
- Cardio: No chest pain
- Pulm: No dyspnea or shortness of breath
- GI: No change in appetite prior to this episode. No diarrhea or blood in stool
- HEENT: No cough or congestion
- Genitourinary: no change in color of urine
- Temp: 99.3 F
- BP: 114/65 mmHg
- HR: 103 bpm
- Respirations: 19/minute
- BMI: 30 Kg/m^2
Focused Physical Exam
- Gen – Patient is alert, seated but bent forward and appears to be in acute distress. She appears to be stated age.
- HEENT – No icterus of the sclera.
- Heart – Tachycardia but normal S1, S2 without murmur.
- Lungs – Lungs are clear to auscultation. No rales or wheezing.
- Abdomen – Some old straie on inspection. No cullen or grey turner sign. Bowel sounds present. Tenderness in the epigastric region and RUQ. Positive murphy sign. Some guarding.
Differential Diagnosis: (Ranked most likely to less likely)
a. Acute Cholecystitis: Associated with constant pain usually > 6 hours. Worse after meals and can be associated with N/V, posituve muprhy sign. Can also be associated with low-grade fever.
b. Choledocholithiasis: Risk factors include across (Forty (>40 y/o), fair (caucasian), fat (obese), fertile (multiparity), female, and family hx). This patient has most of these factors. Can also have signs like previous episodes of abdominal pain, N/V and RUQ pain but note the pain her is colicky and not usually constant. Uncomplicated choledocholithiasis is also less like to have a positive murphy sign.
c. Biliary Pancreatitis: The presence of the risk factors of choledocholithiasis can can also inc. the risk of pancreatitis as the obstruction by the stone depending on its location can also affect the pancreas. N/V and pain after eating that radiates to the back can be seen with this condition too. Improvement of pain by leaning forwards also may be seen with acute pancreatitis. This condition was less likely because it would most likely not be associated with a positive murphy sign and RUQ.
Other differentials are: Acute Cholangitis, Acute hepatitis, Gastritis, Perforated Ulcer, Appendicitis
Ultrasound of the abdomen: stones are noted in a distended gall bladder, gall bladder wall is thickened, pericholecystic fluid?
Alkphos: 123 IU/L, Total Bilirubin: 1.6 mg/dl, AST: 60 IU/L ALT: 40 IU/L
Amylase: 120 U/L Lipase: 80 U/L
CBC: WBC: 11.3 x10E3/uL
Calcium: 9.5 mg/dl
a. IV fluids (5 to 10 mL/kg/hr NS), NPO, NG tube if currently vomiting, analgesia (ketorolac)
b. IV abx (Imipenem-cilastatin; 500 mg IV every 6 hours)
c. Cholecystectomy (preferred to be done ealry with 3 days on onset of sxs). Emergency removal if there is a perforation or abscess of the gall bladder.
- Screen for alcohol use disorder and counsel
- Counsel on weight loss and need for improved diet (lower cholesterol and fatty fats, and high carbs)
Tips for identifying Acute Cholecystitis:
– History of biliary colic
– Unrelenting RUQ that may radiate to shoulder
– Nausea and vomiting (common)
– Low grade fever
– Murphy’s signs & RUQ tenderness
– Labs: Mild leukocytosis with left shift, Mild elevations of Bilirubin, AST/ALT, Alkphose and Amylase
– Imaging: US- can show presence of stones in the gall bladder, a distended gall bladder, a thickened gall bladder wall and can show presence of pericholecystic fluid which can be pathognomic for cholecystitis.