Question

A 36-year-old woman presents to the emergency room with a history of right upper quadrant pain, shaking chills and jaundice. This pain came on suddenly 6 hours earlier and has been progressing. She took her temperature at home and it was 102 F. She vomited once at the onset of pain. She has had intermittent episodes of epigastric and right upper quadrant pain after eating, for the past 6 months. The pain always abated after 30-60 minutes. Her BP is 110/60 mmHg, her pulse is 110/min. and her temperature is 39C in the emergency room.

WBC ct	18.7 x 1000/mm3
Total bilirubin	8.4 mg/dL
Direct bilirubin	7.1 mg/dL
Lipase	15
Hgb	13.5

• What is your differential diagnosis based on the patient’s history and physical examination?

• What imaging studies, if any, would you order for this patient?

• How would you manage this patient?

• Explain the mechanism of gall stone formation.

• What types of gall stones can be formed?

• What factors predispose to the formation of gall stones?

• How is extra-hepatic obstructive jaundice differentiated from other etiologies?

• What are the etiologies of non-obstructive jaundice?

• What are the etiologies of obstructive jaundice? What tests would you use to differentiate etiologies of obstructive jaundice?

Answer 1

1. Differential Diagnosis of  this patient is ACUTE CHOLECYSTITIS. Acute Cholecystitis is inflammation of the gall bladder that develops over hours, usuall because a gall stone obstructs the cystic duct. Symptoms include right upper quadrant pain & tenderness, sometimes accompanied by fever, chills, nausea & vomiting
2. Imaging studies needed: ABDOMINAL ULTRASONOGRAPHY(detects the gall stone and sometimes associated inflammation), X-RAY, CHOLESCINTIGRAPHY if Ultrasonography results are equivocal or if calculous cholecystitis is suspected.
3. Management of Acute Cholecystitis: SUPPORTIVE CARE(HYDRATION, ANALGESICS, ANTIBIOTICS), CHOLECYSTECTOMY. NPO status is advised, Nasogastric suctioning is done if vomiting or an ileus is present.
4. Mechanism of gall stones formation: includes 3 main pathways in the formation of gall stones. a) CHOLESTEROL SUPERSATURATION (if the liver produces excess cholesterol than bile can dissolve , the excess cholesterol may precipitate as crystals, which can be trapped in gall bladder mucus and produces gall bladder sludge and finall gall bladder stones) b). EXCESS BULIRUBBULIRUBIN (excess BULIRUBIN production due to certain hematologic conditions may also cause gall stones) c). GALL BLADDER HYPOMOTILITY OR IMPAIRED CONTRACTILITY (if gall bladder does not empty effectively, bile may become concentrated and form gall stones)
5. Types of gall stones: CHOLESTEROL GALL STONES & PIGMENTED OR CALCIFIED GALL STONES
6. Factors predisposing for gall bladder stone: FEMALE GENDER, AGE 40 OR OLDER, OBESITY, SEDENTARY LIFESTYLE, TAKING HIGH FAT DIET