A 42-year-old obese woman with a history of chronic alcoholism presents with right upper quadrant abdominal pain that began shortly after she had dinner at a local steakhouse. The pain is sharp, rated 7/10 in severity, and radiates to her right scapula. She also complains of nausea and vomiting. Her medical records indicate she has a history of asymptomatic gallstones. She drinks approximately 6 beers a day for the past 20 years but denies tobacco or illicit drug use. Her temperature is 38.5 C (101.3 F), blood pressure is 110/60 mm Hg, pulse is 96/min, and respirations are 16/min. On physical examination, there is right upper quadrant tenderness with deep inspiration. The rest of her examination is within normal limits. Laboratory studies are shown below. Complete blood count shows leukocytosis with mild left shift. Which of the following is the most likely initial event leading to this patient's symptoms?

Question

A 42-year-old obese woman with a history of chronic alcoholism presents with right upper quadrant abdominal pain that began shortly after she had dinner at a local steakhouse.  The pain is sharp, rated 7/10 in severity, and radiates to her right scapula.  She also complains of nausea and vomiting.  Her medical records indicate she has a history of asymptomatic gallstones.  She drinks approximately 6 beers a day for the past 20 years but denies tobacco or illicit drug use.  Her temperature is 38.5 C (101.3 F), blood pressure is 110/60 mm Hg, pulse is 96/min, and respirations are 16/min.  On physical examination, there is right upper quadrant tenderness with deep inspiration.  The rest of her examination is within normal limits.  Laboratory studies are shown below.  Complete blood count shows leukocytosis with mild left shift.  Which of the following is the most likely initial event leading to this patient's symptoms?

Quizplus · Accepted Answer

This patient presents with findings consistent with acute cholecystitis, which usually presents with sudden onset of steady epigastric or right upper quadrant pain after a large or fatty meal. The pain may radiate to the right scapula or be accompanied by Murphy's sign, described as worsening of right upper quadrant pain with inspiration that sometimes causes the patient to suddenly hold their breath. Other classical findings include fever, vomiting, and leukocytosis. Uncomplicated cholecystitis can cause mild elevations in transaminases, total serum bilirubin from 1-4 mg/dL, and serum amylase without obvious common bile duct or pancreatic disease. In these cases, the laboratory elevations are usually due to passage of sludge or pus in the common bile duct. However, alkaline phosphatase is usually not elevated without associated cholangitis or choledocholithiasis. Acute cholecystitis is secondary to gallstone formation in over 90% of cases, most commonly arising when a gallstone impacts in the cystic duct. Ingestion of fatty foods then stimulates the contraction of the gallbladder against the obstructed cystic duct, and leads to severe colicky pain. The tissue behind the duct obstruction becomes inflamed, from stasis leading to bacterial overgrowth. The subsequent ischemic changes most commonly lead to gangrene and perforation, generalized peritonitis, or a well-circumscribed abscess. Other potential complications include cholangitis and chronic cholecystitis. Treatment for acute cholecystitis includes supportive care (nothing by mouth, intravenous antibiotics, and analgesics). Laparoscopic cholecystectomy is recommended shortly after hospitalization and should be performed immediately in cases of perforation or gangrene. (Choice B) Although infection of the gallbladder is present in 50-70% of acute cholecystitis cases, the original inciting event is gallstone impaction in the cystic duct. Therefore, infection would not be the primary mechanism for this patient's symptoms. (Choices C and D) Common bile duct obstruction with stone or carcinoma would normally cause obstructive jaundice characterized by severe icterus and very high alkaline phosphatase levels. (Choice E) Alcohol toxicity can cause acute pancreatitis but is not usually associated with acute cholecystitis. Educational objective: Acute cholecystitis usually presents with sudden onset of right upper quadrant abdominal pain, fever, vomiting, and leukocytosis. The primary inciting event is a gallstone obstructing the cystic duct with subsequent inflammation and infection References: Hyperbilirubinemia without common bile duct abnormalities and hyperamylasemia without pancreatitis in patients with gallbladder disease. (http://www.ncbi.nlm.nih.gov/pubmed/7519418)

A 42-Year-Old Obese Woman with a History of Chronic Alcoholism