A 36-year-old woman comes to the emergency department after having severe epigastric and right shoulder pain for 2 hours. The patient also had an episode of emesis. When asked about her diet, she explains that she unintentionally fasted all day and had a cheeseburger 2 hours ago. The patient had a similar episode last month but did not seek medical attention as it was less severe and resolved spontaneously in a few hours. Her past medical history is significant for heartburn, and she takes ranitidine. On examination, the patient's abdomen is soft and nontender. About 4 hours after the pain began, it resolves completely. Which of the following best explains this episode?

Question

A 36-year-old woman comes to the emergency department after having severe epigastric and right shoulder pain for 2 hours.  The patient also had an episode of emesis.  When asked about her diet, she explains that she unintentionally fasted all day and had a cheeseburger 2 hours ago.  The patient had a similar episode last month but did not seek medical attention as it was less severe and resolved spontaneously in a few hours.  Her past medical history is significant for heartburn, and she takes ranitidine.  On examination, the patient's abdomen is soft and nontender.  About 4 hours after the pain began, it resolves completely.  Which of the following best explains this episode?

Quizplus · Accepted Answer

This is the classic presentation of biliary colic secondary to gallstones. Ingestion of a large (usually fatty) meal stimulates gallbladder contraction. The intra-gallbladder pressure increases on gallbladder contraction against an obstructed cystic duct and causes pain. Subsequent gallbladder relaxation allows the stone to fall back from the duct with subsequent pain resolution. The pain is in the right upper quadrant or epigastric region, often constant (rather than colicky), and accompanied by nausea, vomiting, and right-sided shoulder or subscapular discomfort (referred pain). Patients may have recurrent symptoms that resolve between episodes. Features that distinguish biliary colic from cholecystitis are pain resolution within 4-6 hours and absence of abdominal tenderness, fever, and leukocytosis. gallstones (Choice A) Epigastric discomfort is accompanied by heartburn secondary to gastric acid hypersecretion and mucosal irritation. However, pain is usually described as a burning sensation and does not radiate to the right shoulder. Dyspepsia provoked by meals is often associated with belching and early satiety. Vomiting may occur but is uncommon. (Choice B) Fat necrosis may accompany acute pancreatitis. Symptoms include nausea, vomiting, and constant epigastric pain that radiates to the back. Pain usually does not resolve spontaneously within a few hours. (Choice D) In acute cholecystitis, the gallbladder mucosa is inflamed. The cystic duct is frequently obstructed with gallstones or sludge. Although the pain is similar to biliary colic pain in location, radiation, and associated symptoms, it usually lasts longer than 6 hours. Furthermore, patients frequently have fever, leukocytosis, and tenderness to palpation in the midaxillary line under the right costal margin (Murphy's sign). acute cholecystitis (Choice E) Rebound tenderness, abdominal guarding, and decreased bowel sounds are found on abdominal examination in patients with peritoneal irritation. This patient's abdominal examination is benign. (Choice F) Bowel ischemia from vascular obstruction causes severe abdominal pain out of proportion to findings on physical examination. The pain is often periumbilical, lasts longer than that of biliary colic, does not resolve spontaneously, and is frequently accompanied by nausea, vomiting, and fecal blood. Educational objective: Biliary colic occurs due to increased intra-gallbladder pressure that is created when the gallbladder contracts against an obstructed cystic duct. The pain is exacerbated by fatty meals, usually lasts less than 6 hours, and resolves completely between episodes. There is no fever, abdominal tenderness on palpation, or leukocytosis. References: Natural history of gallstone disease: Expectant management or active treatment? Results from a population-based cohort study. (http://www.ncbi.nlm.nih.gov/pubmed/20492328)

A 36-Year-Old Woman Comes to the Emergency Department After Having