Ch. 15 Postprandial RUQ Pain Flashcards
What is her most likely dx?
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.
What is the differential dx?
Why is the term biliary colic a misnomer? What is a better term?
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.
What are the main risk factors for developing cholesterol gallstones?
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)
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)
Symptomatic cholelithiasis = usually managed as an outpatient, wih eventual elective lap cholecystectomy
Acute cholecystitis = requires hospital admission, IV abx, urgent cholecystectomy
What is the significance of abdominal pain after eating fatty foods?
What is the pathophysiology?
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)
What is the significant of RUQ pain combined with scapular pain?
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
What is the significance of the patient’s inspiration stopping with RUQ palpation?
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
What is the difference between somatic and visceral pain?
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
What is chronic cholecystitis?
Recurrent bouts of symptomatic cholelithiasis –> chronic inflammation of gallbladder with fibrotic changes seen on histo exam
What causes acute cholecystitis?
What are the typical organisms in the bile?
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
What are the components of bile? (3)
Three main components:
bile salts, cholesterol, lecithin (phospholipid)
What are the different manifestations of gallstone disease? (7)
What is the diagnostic test of choice?
RUQ U/S
What is the normal CBD diameter, and what is the implication of a dilated CBD?
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