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. Abdominal ultrasound is performed and shows a nondistended gallbladder with numerous gallstones. The size of the common bile duct is normal (0.5 cm), but the pancreas is not well visualized. Complete metabolic panel is normal. Which of the following is the most appropriate next step in management of this patient?

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Explanation: 11ec2b69_bf35_3b62_8f63_57c64cf14158_MD0005_00 Management of gallstones depends on the patient's symptoms, imaging findings, and presence of complications. Those with typical biliary colic symptoms and confirmed gallstones (such as this patient) are treated symptomatically with pain management. Patients then undergo prophylactic elective cholecystectomy (usually laparoscopic) to prevent recurrence and complications (eg, choledocholithiasis, cholangitis, gallbladder rupture). (Choice A) Cholecystokinin-stimulated cholescintigraphy evaluates for gallbladder ejection fraction, which is low in patients with functional gallbladder disease. This study is generally reserved for patients with typical biliary colic symptoms without confirmed gallstones on imaging. Patients with a positive test result should undergo cholecystectomy; those with a negative test result are evaluated for other causes of abdominal pain. (Choice B) CT scan of the abdomen with contrast can evaluate for other causes of abdominal pain (eg, pancreatitis) and would be indicated if this patient had a normal abdominal ultrasound. Although the pancreas was not well visualized, pancreatitis due to gallstones in the biliary tree typically dilates the common bile duct. This patient's normal-size common bile duct makes this less likely. (Choice D) Lithotripsy uses shock waves to fragment and remove difficult biliary and pancreatic duct stones. However, it is not as effective for gallstones within the gallbladder. (Choice E) Ursodeoxycholic acid (UDCA) is used for patients with symptomatic gallstones who are poor surgical candidates. It can also be given as a trial to patients with confirmed gallstones who have atypical symptoms (ie, lacking biliary colic). Patients who respond to UDCA should undergo cholecystectomy; nonresponders are evaluated for other causes of abdominal pain. Educational objective: Management of gallstones depends on the patient's symptoms, imaging findings, and presence of complications. Patients with typical biliary colic symptoms and confirmed gallstones are usually given acute pain management and undergo prophylactic therapy with elective cholecystectomy. References: Surgical treatment of gallstones. (http://www.ncbi.nlm.nih.gov/pubmed/20478484)

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