A 36-year-old woman comes to the office due to intermittent abdominal pain. She has had 5 episodes of pain over the past several weeks. The pain is dull, is located in the right upper quadrant and epigastrium, and often radiates to her back. The pain occurs only after eating and lasts 30-60 minutes. It is not relieved by antacids. The pain is occasionally associated with nausea and vomiting, but the patient has no hematemesis, melena, or weight loss. She does not use nonsteroidal anti-inflammatory drugs, tobacco, or alcohol. Her father died of pancreatic cancer at age 64. Temperature is 37.5 C (99.5 F), blood pressure is 142/89 mm Hg, pulse is 67/min, and respirations are 12/min. BMI is 32 kg/m². The abdomen is tender to palpation in the right upper quadrant and epigastrium but is nondistended and without rebound or guarding. Laboratory results are as follows: Which of the following is the best next step in management of this patient?

Question

Quizplus · Accepted Answer

This patient's presentation suggests biliary colic, which occurs when the gallbladder contracts against a gallstone (or sludge) that is temporarily blocking the cystic duct. Risk factors for gallstone disease include female sex, age >40, hypertriglyceridemia, and obesity. Patients classically develop dull postprandial right upper quadrant (RUQ) or epigastric pain that worsens over an hour and subsides with gallbladder relaxation. Nausea, vomiting, and diaphoresis may occur; however, vital signs, white blood cell count, and liver function tests (LFTs) should remain normal. The best test to evaluate biliary colic is a RUQ abdominal ultrasound, which can confirm the presence of gallstones. Acute cholecystitis, a common complication of gallstone disease, can occur with complete obstruction of the cystic duct. In contrast to biliary colic, acute cholecystitis typically presents with severe, unremitting RUQ pain and signs of systemic illness (eg, fever, tachycardia, leukocytosis). LFTs typically remain normal, and elevations should raise suspicion for biliary obstruction (eg, choledocholithiasis, cholangitis). Characteristic ultrasound findings of cholecystitis include gallbladder wall thickening, edema, and pericholecystic fluid. (Choices B and C) Most gallstones are radiolucent and may not be detected on abdominal x-ray or CT scan. CT scan can be helpful in ruling out pancreatic cancer, which can also cause epigastric pain. However, despite this patient's family history, pancreatic cancer is exceedingly rare in young individuals and would typically present with weight loss and progressive pain. (Choice D) Testing for Helicobacter pylori is ideal in patients with dyspepsia. However, although postprandial epigastric pain is common, it is usually described as burning (as opposed to dull) and relieved by antacids. Importantly, dyspepsia is not associated with vomiting. (Choice E) A HIDA scan is used to diagnose acute cholecystitis in patients with an equivocal abdominal ultrasound. It is not indicated as first-line imaging. Additionally, this patient does not have signs of cholecystitis (eg, fever, leukocytosis). (Choice F) Upper gastrointestinal endoscopy is useful for ruling out peptic ulcers, but the postprandial abdominal pain is often described as burning and relieved by antacids. Major risk factors are nonsteroidal anti-inflammatory drug use and H pylori infections. Educational objective: Biliary colic occurs when the gallbladder contracts against a gallstone that temporarily blocks the cystic duct. Classic symptoms include episodic postprandial right upper quadrant or epigastric pain, nausea, and vomiting; however, vital signs, white blood cell count, and liver function studies remain normal. The diagnosis is confirmed with an abdominal ultrasound demonstrating the presence of gallstones.

A 36-Year-Old Woman Comes to the Office Due to Intermittent