15: 42-year-old man with right upper quadrant pain Flashcards
CAGE & AUDIT Screening for Alcohol Abuse/Dependence
The CAGE questionnaire is a classic series of screening questions for the likelihood of alcohol abuse and/or dependence.
Positive answers to two or more of the CAGE questions are sufficient to identify individuals who require more intensive evaluation. Also, a positive answer to the question, “Have you ever had a drinking problem?” plus evidence of alcohol consumption in the previous 24 hours provides greater than 90% sensitivity and specificity as a screening tool for identifying alcoholism.
The CAGE questionnaire has consistently proved to be a useful instrument for detecting alcohol abuse and alcohol dependence.
Modified CAGE:
Have you ever felt:
1. The need to Cut down on drinking?
2. Annoyed with criticisms about your drinking?
3. Guilt about your drinking?
4. The need to drink an Eye opener in the morning?
Furthermore, the American Society of Addiction Medicine has developed standards for a positive screen based on the number of drinks ingested per week. Consumption of more than 14 drinks per week or more than 4 drinks per occasion for men, and more than 7 drinks per week or more than 3 drinks per occasion for women is considered a positive screen.
The AUDIT-C is another example of a screening questionnaire. It is a three item alcohol screen that can help identify persons who are hazardous drinkers or have active alcohol use disorders (including alcohol abuse or dependence).
Alcohol Use Disorder According to DSM 5 is diagnosed when patients endorse two or more of the following:
More than once wanted to cut down or stop drinking, or tried to, but couldn’t.
Spent a lot of time drinking, being sick from drinking, or getting over the after-effects of drinking.
Experienced craving - a strong need, or urge, to drink.
Found that drinking - or being sick from drinking - often interfered with taking care of his/her home or family; has caused job troubles or school problems.
Continued to drink even though it was causing trouble with family or friends.
Given up or cut back on activities that were important or interesting to the patient or gave him/her pleasure, in order to drink.
More than once gotten into situations while or after drinking that increased the patient’s chances of getting hurt (such as driving, swimming, using machinery, walking in a dangerous area, or having unsafe sex). Continued to drink even though it was making the patient feel depressed or anxious or adding to another health problem, or after having had a memory blackout.
Had to drink much more than he/she once did to get the effect he/she wanted, or found that his/her usual number of drinks had much less effect than before.
Found that when the effects of alcohol were wearing off, the patient had withdrawal symptoms, such as trouble sleeping; shakiness; irritability; anxiety; depression; restlessness; nausea; or sweating, or r sensed things that were not there.
Alcohol Use Disorder severity is graded according to the following:
Mild: Two to three symptoms.
Moderate: Four to five symptoms.
Severe: Six or more symptoms.
Classifying Alcohol Use
Moderate Drinking means the patient’s alcohol consumption is up to one drink per day for women and up to two drinks per day for men.
Binge Drinking is defined by the Substance Abuse and Mental Health Service Administration (SAMHSA) as the consumption of five or more alcoholic beverages on one occasion on one or more days in a 30-day period.
Heavy Drinking is defined by SAMHSA as consuming five or more alcoholic drinks on a single occasion, five or more days in a 30-day period.
Abdominal Exam - Appendicitis
Psoas sign: Passive extension of patient’s thigh as s/he lies on his/her side with knees extended, or asking the patient to actively flex his/her thigh and hip causes abdominal pain, often indicative of appendicitis.
Obturator Sign: Examiner has patient supine with right hip flexed to 90 degrees; takes patient’s right ankle in his right hand as he uses his left hand to externally/internally rotate patient’s hip by moving the knee back and forth. Elicitation of pain in the abdomen implies acute appendicitis.
Management of Biliary Colic
Surgical consultation for cholecystectomy.
Expectant management or “watchful waiting” would not be appropriate as natural history studies document a 70% risk of progression over two years to complications such as cholangitis, pancreatitis, cholecystitis, choledocholithiasis, gallstone ileus and Mirizzi syndrome (gallstone compression of the hepatic duct).
A three-month trial of ursodiol (Actigall) - an agent that is sometimes effective in dissolving gallstones and preventing future gallstones - would be equivalent to watchful waiting in many clinical circumstances. If the patient is having more atypical symptoms with visible stones, which may or may not account for the symptoms, then such a medical trial might be warranted. If symptoms resolve, then they may have been from the gallstones and subsequent therapy can be planned. If symptoms do not resolve, then plans can likewise be made.
Further imaging is probably not warranted. If the patient has typical symptoms of biliary colic but no visible stones on the gallbladder ultrasound, a HIDA scan might be obtained to look for gallbladder dysfunction and reproducible pain.
If there was jaundice and/or gallstone pancreatitis suggestive of a common duct stone (choledocholelithiasis), an ERCP might be warranted.
Another role for ERCP would be in the postoperative patient who did not have an intraoperative cholangiogram (assessing the common duct at the time of surgery) and who presents with a repeat episode of biliary colic and/or jaundice and/or pancreatitis. MRCP is a similar diagnostic modality that uses magnetic resonance. However, unlike ERCP - where treatment can take place at the time of diagnosis… MRCP is a diagnostic modality only.
Intervention and Treatment of Alcohol Use Disorder
Brief intervention by the family physician consisting of a 10- to 15-minute session with advice and goal- setting. Usually this is followed by return visit or phone call. This is the most likely option to choose for a patient in a rural area.
Referral for CBT, a structured form of psychotherapy that works to improve the patient’s awareness of his behavior and to develop new, more adaptive behaviors. Also requires patient commitment and may not be readily accessible in a rural area.
Referral for MET consisting of four sessions over 12 weeks utilizing techniques of motivational interviewing. This intervention requires more of a commitment from the patient to attend sessions. This modality may not be available in a rural area.
Treatment with medication: The Agency for Healthcare Research and Quality found moderate evidence to support the use of naltrexone and acamprosate for the treatment of alcohol use disorder.
Voluntary participation in AA . This program is available in almost all regions and utilizes group support and a Twelve-Step process emphasizing total alcohol abstinence.
Studies to Evaluate Right Upper Quadrant Abdominal Pain
CBC (complete blood count) is indicated to assess for leukocytosis that would suggest infection or acute cholecystitis and to assess for anemia that might suggest internal bleeding.
Electrolytes are indicated to assess for electrolyte alterations due to his recent vomiting.
LFT (liver function testing) is indicated to assess for acute or chronic hepatic cell injury (elevated ALT and AST) and to assess for biliary tract involvement (elevated alkaline phosphatase and total bilirubin).
Amylase/lipase are indicated to assess for pancreatitis.
Imaging Right Upper Quadrant Abdominal Pain
In general, real-time abdominal ultrasonography is the preferred study to evaluate the right upper quadrant because it is inexpensive, noninvasive, and widely available. It provides a good evaluation of the liver and other viscera such as the gallbladder, and it is accurate in the detection of gallstones and dilation of the biliary tree.
Abdominal upright and flat plate x-ray is often readily available and relatively inexpensive compared to the other imaging studies listed, it is not the most sensitive modality for evaluation of the right upper quadrant. It is good for evaluation of free air in the gastrointestinal tract, calcifications in the renal or gastrointestional tract, and signs of bowel obstruction making it the initial imaging modality of choice for suspected visceral perforation or intestinal obstruction.
Abdominal CT Scan with contrast is more appropriate for the initial work up of right lower quadrant abdominal pain such as that due to appendicitis and relatively less sensitive in sorting out the anatomy and pathophysiology of the right upper quadrant. Additionally, it is more expensive and involves radiation.
Abdominal MRI, although very sensitive, is expensive, not always available, and wouldn’t be a first choice study before ultrasound in most cases.
Differential of Right Upper Quadrant Abdominal Pain
Biliary colic typically causes right upper quadrant pain, epigastric pain or chest pain that is constant (the term “colic” is a misnomer), typically lasts 4-6 hours or less, and often radiates to the back (classically under the right shoulder blade). It is often accompanied by nausea or vomiting and often follows a heavy, fatty meal. These symptoms are a result of a stimulated gallbladder (e.g., from a fatty meal) contracting when a gallstone obstructs the outlet of the cystic duct. The hallmark of biliary colic is that the stone is mobile and eventually moves away from the outlet allowing resumption of normal gallbladder function and resolution of symptoms.
RUQ pain from cholecystitis also causes right upper quadrant pain with associated nausea and vomiting and also classically occurs following a large, fatty meal. The pathophysiology of cholecystitis is similar to biliary colic but is caused by a stone that is not dislodged from the cystic duct outlet. In contrast to biliary colic, the symptoms of cholecystitis typically persist, are more severe, and are often associated with fever. An elevated white blood cell count is often present from inflammation of the distended gallbladder wall. It should be noted that these inflammatory changes found with cholecystitis can be acute or chronic. Additionally, the condition of acalculous cholecystitis is recognized, particularly in the elderly and the very-ill ICU patient.
A positive Murphy’s sign (which Mr. Keenan lacks) is the classic physical finding associated with acute cholecystitis. A negative Murphy’s sign would not rule out cholecystitis however, as Murphy’s sign has high specificity but low sensitivity.
Duodenal ulcer typically causes epigastric pain (possibly right or left upper quadrant pain) that is relieved rather than worsened by food and is relieved by antacids. While indigestion and/or nausea are common, vomiting and radiation to the back can occur but are uncommon. However, there can be significant variation in symptoms.
The clinical manifestations of hepatitis vary somewhat depending on etiology, but most types do not have acute onset, unlike the diseases of the gallbladder tract. While RUQ pain, nausea, and vomiting are frequently encountered, there is often associated malaise, anorexia, itching, and icterus/jaundice. Hepatomegaly is often present.
Nausea, vomiting and epigastric pain are hallmarks of acute pancreatitis. Typically, however, there is abdominal tenderness on exam and there is unlikely to be resolution of symptoms without prolonged bowel rest, and jaundice may be seen if there is obstruction of the common bile duct. Distinguishing acute pancreatitis from biliary colic (and any other upper abdominal disease) can be challenging, particularly because the two most common etiologies of acute pancreatitis are alcoholic pancreatitis and gallstone pancreatitis. Gallstone pancreatitis may be preceded by an episode of biliary colic. With the onset of acute pancreatic inflammation as the pancreatic duct is obstructed, the pain worsens rapidly and radiates to the back. Some classic, though rare, physical exam signs seen in acute pancreatitis include:
- Grey Turner sign: ecchymotic discoloration in the flank
- Cullen sign: ecchymotic discoloration in the periumbilical region
Finally, the presentation of acute pancreatitis may include shock and/or coma.
