2. CASE 1
A 38-year-old woman is brought to the emergency department
because of three 1-hour episodes of severe, sharp, penetrating
abdominal pain in the right upper quadrant. During these
episodes, she has had nausea and vomiting. She has no diarrhea,
dysuria, or hematuria and is asymptomatic between episodes.
She has hypertension and hyperlipidemia.
3. She is 155 cm (5 ft 2 in) tall and weighs 79 kg (175 lb); BMI is 32
kg/m2. Her temperature is 36.9°C (98.5°F), pulse is 80/min, and
blood pressure is 130/95 mm Hg. There is mild scleral icterus.
Cardiopulmonary examination shows no abnormalities. The
abdomen is soft, and there is tenderness to palpation of the right
upper quadrant without guarding or rebound. Bowel sounds are
normal. The stool is brown, and test for occult blood is negative.
What is your Impression?
What are the Ddx?
What investigations would you order?
5. Lab Reference Ranges
• Hemoglobin: Male 13.5 to 17.5g/dl Females 12.0 to 16.0g/dl
• Leukocyte Count: 4.5 to 11 × 10^9/L Neutrophils: 54 to 62%
• Platelet Count: 150,000 to 400,000/mm3
• Total Bilirubin // Direct Bilirubin: 0.1 to 1mg/dL // 0.0 to
0.3mg/dL
• ALP: 25 to 100 U/L
• AST: 12 to 38 U/L
• ALT: 10 to 40 U/L
• Amylase: 25 to 125 U/L
6. Abdominal ultrasonography shows a normal liver, a common
bile duct caliber of 10 mm (N < 6) and a gallbladder with
multiple gallstones and no wall thickening or pericholecystic
fluid
What is your diagnosis?
What are the Clinical Features of this condition?
What is the management of this condition?
7.
8.
9. CASE 2
Fourteen days after a laparoscopic cholecystectomy for
cholelithiasis, a 45-year-old woman comes to the emergency
department because of persistent episodic epigastric pain for 3
days. The pain radiates to her back, occurs randomly throughout
the day, and is associated with nausea and vomiting. Each
episode lasts 30 minutes to one hour. Antacids do not improve
her symptoms. She has hypertension and fibromyalgia. She has
smoked 1–2 packs of cigarettes daily for the past 10 years and
drinks 4 cans of beer every week. She takes lisinopril and
pregabalin.
10. Examination
She appears uncomfortable. Her temperature is 37.0°C (98.6° F),
pulse is 84/min, respirations are 14/min, and blood pressure
is 127/85 mm Hg. Abdominal examination shows tenderness to
palpation in the upper quadrants without rebound or guarding.
Bowel sounds are normal. The incisions are clean, dry, and intact
11. Findings
Serum studies show:
AST 80 U/L
ALT 95 U/L
Alkaline phosphatase 213 U/L
Bilirubin, total 1.9 mg/dL
Direct 0.7 mg/dL
Amylase 52 U/L
12. Abdominal ultrasonography shows a common bile duct
measuring 11 mm in diameter and no gallstones.
What condition is this. What is it’s pathophysiology?
Which of the following is the most appropriate next step in
management?
What is the management in this patient?
13. CASE 3
One week after undergoing sigmoidectomy with end colostomy
for complicated diverticulitis, a 67-year-old man has upper
abdominal pain. During the surgery, he was transfused two units
of packed red blood cells. His postoperative course was
uncomplicated. Two days ago, he developed fever. He is
currently receiving parenteral nutrition through a central venous
catheter. He has type 2 diabetes mellitus, hypertension, and
hypercholesterolemia. He is oriented to person, but not to place
and time. Prior to admission, his medications included
metformin, valsartan, aspirin, and atorvastatin.
14. His temperature is 38.9°C (102.0°F), pulse is 120/min, and blood
pressure is 100/60 mm Hg. Physical examination shows mild
conjunctival icterus. Abdominal examination shows tenderness
to palpation in the right upper quadrant. There is no rebound
tenderness or guarding; bowel sounds are hypoactive
What is your impression?
16. Which of the following is the most likely diagnosis?
Classify this condition?
How does this condition present?
What are the investigations in this condition?
What is the management in this condition?
17. CASE 4
A 43-year-old woman comes to the emergency department
because of a 3-hour history of upper abdominal pain that radiates
to her right shoulder and upper back. During this period, she has
also had nausea and one episode of nonbloody vomiting. She
says the pain is dull and constant. One hour prior to the onset of
her current symptoms, she was eating a hamburger and french
fries at a local restaurant. She has hypertriglyceridemia and
hypertension. She drinks one to two glasses of wine daily.
18. She is 153 cm (5 ft) tall and weighs 92 kg (203 lb); BMI is 39
kg/m2. Her temperature is 36.3°C (97.3°F), pulse is 84/min,
respirations are 22/min, and blood pressure is 135/85 mm Hg.
The abdomen is soft and there is mild right upper quadrant
tenderness to palpation; there is no guarding or rebound.
What is your Impression?
What are the appropriate Investigations?
19. • Laboratory studies show a leukocyte count of 9,000/mm3, AST
activity of 35 U/L, and ALT activity of 36 U/L; total bilirubin
concentration is 0.9 mg/dL
• Discuss the condition causing her symptoms
20. CASE 5
A 35-year-old woman comes to the physician because of nausea
and severe abdominal pain for 2 weeks. The pain worsens after
meals and, according to the patient, “can last a whole day.” She
tried taking ibuprofen for the pain, but it provided only minimal
relief. She has no personal or family history of severe illness. Her
only medication is an oral contraceptive.
21. EXAMINATION
• She appears uncomfortable. Her temperature is 37.5°C (99°F),
pulse is 78/min, respirations are 19/min, and blood pressure
is 118/75 mm Hg. She is 172 cm (5 ft 7 in) tall and weighs 82
kg (180 lb); BMI is 28 kg/m2. Examination shows tenderness in
the right upper quadrant on abdominal palpation. The liver and
spleen cannot be palpated. The remainder of the physical
examination shows no abnormalities
22. What is your impression?
What are your differential diagnosis?
What are appropriate investigations to order?
23. Labs
Laboratory studies show:
Hemoglobin 13.3 g/dL
Hematocrit 43% Normal
Leukocyte count 13,700/mm3
Serum
Glucose 70 mg/dL Normal
Creatinine 1.1 mg/dL Normal
Total bilirubin 1 mg/dL
Alkaline phosphatase 120 U/L
γ-Glutamyl transpeptidase 35 U/L (N = 5–50)
AST 49 U/L
ALT 60 U/L
24. Results of a right upper quadrant ultrasonography are
inconclusive
What is the most appropriate next investigation in this patient?
What are the findings of this investigation?
What are the management modalities in this patient?
25.
26.
27.
28. CASE 6
A 42-year-old woman is brought to the emergency department
because of intermittent sharp right upper quadrant abdominal
pain and nausea for the past 10 hours. She vomited three times.
There is no associated diarrhea, or urinary symptoms. She has
two children who both attend high school. She appears
uncomfortable.
29. She is 165 cm (5 ft 5 in) tall and weighs 86 kg (190 lb); BMI is 32
kg/m2. Her temperature is 38.5°C , pulse is 100/min, and blood
pressure is 140/90 mm Hg. She has scleral icterus. The abdomen
is soft and nondistended, with tenderness to palpation of the
right upper quadrant without guarding or rebound. Bowel
sounds are normal
What is your impression?
What are the appropriate investigations?
What are your expectations in those investigations?
31. What is the appropriate management for this patient?
32. CASE 7
An otherwise healthy 56-year-old woman comes to the physician
because of a 3-year history of intermittent upper abdominal pain.
She has had no nausea, vomiting, or change in weight. Physical
examination shows no abnormalities. Laboratory studies are
within normal limits. You send her for an abdominal
ultrasonography which shows a hyperechogenic rim-
like calcification of the gallbladder wall.
What is your impression?
What condition is this patient most likely to be predisposed to?
33. CASE 8
A 46-year-old woman comes to the emergency department
because of intermittent abdominal pain and vomiting for 2 days.
The abdominal pain is colicky and diffuse and the patient
describes it as 7 out of 10 in intensity. The patient's last bowel
movement was 3 days ago. She has had multiple episodes of
upper abdominal pain that radiates to her scapulae and vomiting
over the past 3 months; her symptoms subsided after taking
ibuprofen. She has coronary artery disease, type 2 diabetes
mellitus, gastroesophageal reflux disease, and osteoarthritis of
both knees. Current medications include aspirin, atorvastatin,
rabeprazole, insulin, and ibuprofen. She appears uncomfortable
34. Her temperature is 39°C (102.2°F), pulse is 111/min, and blood
pressure is 108/68 mm Hg. Examination shows dry mucous
membranes. The abdomen is distended and tympanitic with
diffuse tenderness; bowel sounds are high-pitched. Rectal
examination shows a collapsed rectum.
What is your impression? Why?
What investigations will you send this patient for?
35. Her hemoglobin concentration is 13.8 g/dL, leukocyte count is
14,400/mm3, and platelet count is 312,000/mm3. An x-ray of the
abdomen was taken and is shown below:
36. ANSWERS
• Case 1: Choledocholithiasis
• Case 2: Post Cholecystectomy Syndrome
• Case 3: Acute Acalculous Cholecystitis
• Case 4: Biliary Colic from Gallstone
• Case 5: Acute Calculous Cholecystitis
• Case 6: Ascending Cholangitis 2° Choledocholithiasis
(Charcoat’s Triad)
• Case 7: Porcelain gallbladder
• Case 8: Gallstone ileus
