A 35-year-old woman comes to the office with episodic abdominal pain. After dinner a day ago, she had intense epigastric pain that lasted 30-40 minutes, was dull with radiation to the back and right shoulder, and was accompanied by nausea and difficulty catching her breath. The pain resolved spontaneously after an hour and she did not seek medical care. The patient has had 2 similar episodes of lesser intensity in the past 6 months that resolved spontaneously. She has a history of migraine headaches treated with sumatriptan as needed. She does not use tobacco or illicit drugs. The patient has consumed 1 or 2 glasses of wine daily for the past 10 years. Her father died of pancreatic cancer at age 75, and her mother died of breast cancer at age 65. Vital signs are within normal limits. BMI is 35 kg/m². Abdominal examination reveals normoactive bowel sounds without tenderness or guarding. The liver span is 8 cm and there is no palpable spleen. The remainder of the examination is within normal limits.
Which of the following is the best next step in management of this patient?

Question

Quizplus · Accepted Answer

Explanation: This patient's presentation suggests biliary colic due to gallstones. Biliary colic is due to contraction of the gallbladder, which forces gallstones or sludge into the cystic duct. The increased pressure within the gallbladder causes pain, which usually decreases as the gallbladder relaxes and the stone moves back from the cystic duct. Patients typically develop epigastric or right upper-quadrant discomfort with radiation to the back and right shoulder. Associated symptoms include nausea, vomiting, and diaphoresis. The entire episode usually lasts for <6 hours. Although fatty meals can trigger the pain, many patients can develop nocturnal symptoms or pain independent of meals. Physical examination in a patient with uncomplicated gallstones is usually benign without peritoneal signs or guarding. Transabdominal ultrasound is initially preferred for diagnosing gallstones as it is reliable (95% sensitive, >95% specific in some studies), noninvasive, and readily available without the need for contrast or radiation. Obesity may make visualization more difficult (although this is operator-dependent) but is not a contraindication for ultrasound. The test is ideally done after an 8-hour fast and can show gallstones (echogenic foci with shadow) or sludge (echogenic foci without shadow). (Choice A) Abdominal plain x-rays are less sensitive for diagnosing gallstones as only 10% have enough calcium to appear radiopaque. (Choice B) CT scan of the abdomen is frequently done to exclude other causes of abdominal pain (eg, pancreatitis, ischemic colitis) but is less sensitive in the detection of gallstones than ultrasound. This patient's presentation is more consistent with gallbladder disease, which should be ruled out first with ultrasound. (Choice C) Helicobacter pylori testing is indicated in patients age <55 with dyspepsia (in high-prevalence areas). Dyspepsia causes postprandial fullness, early satiation, and epigastric burning. Pain does not typically radiate to the shoulder or back. (Choice D) Pancreatitis can present with midepigastric pain radiating to the back and elevated serum lipase. However, pancreatitis typically causes severe pain with inability to tolerate oral intake and examination reveals significant tenderness in the epigastric region. Radiation of pain to the shoulder would be unexpected. Educational objective: Biliary colic presents with episodes of constant epigastric or right upper-quadrant discomfort that can radiate to the back and right shoulder with associated with nausea, vomiting, and diaphoresis. Abdominal examination is usually benign without peritoneal signs or guarding. Transabdominal ultrasound is initially preferred for diagnosis. References: Cholelithiasis and cholecystitis. (http://www.ncbi.nlm.nih.gov/pubmed/16022643)

A 35-Year-Old Woman Comes to the Office with Episodic Abdominal