Hepatobiliary disease and Related disorders

For the scenarios given below chose the most likely diagnosis form the following list.

A. Ascending cholangitis
B. Duodenal ulcer
C. Biliary colic
D. Amoebic liver abscess
E. Pancreatic cancer
F. Viral hepatitis
G. Congestive hepatomegaly
H. Cholangiocarcinoma
I. Gallstone ileus
J. Acute pancreatitis

Q 1. A 57-year-old woman with a history of gallstones presents with progressive right upper quadrant pain, rigors and jaundice.

Answer: Ascending cholangitis
( This is a classical presentation of ascending cholangitis.)

Q 2, A 62-year-old woman presents with upper abdominal pain. She has recently been discharged from hospital where she underwent an ERCP to investigate cholestatic liver function tests. The pain is severe. On examination she is apyrexial and has a pulse of 96 / min.

Answer: Acute pancreatitis.
(Pancreatitis may develop following an ERCP.)

Q 3. A 76-year-old woman presents with abdominal pain, distension and vomiting. She recently had an episode of acute cholecystitis and is awaiting a cholecystectomy. She feels her symptoms have returned over the past few days. On examination her abdomen is distended.

Answer: Gallstone ileus.
( This patient has developed small bowel obstruction secondary to an impacted gallstone.)

Discussion: Below are given characteristic exam question features for conditions causing hepatobiliary disease and related disorders:


1. Viral hepatitis: Common symptoms include:
 nausea and vomiting, anorexia
 myalgia  lethargy
 right upper quadrant (RUQ) pain
Questions may point to risk factors such as foreign travel or intravenous drug use.

2. Congestive hepatomegaly: The liver only usually causes pain if stretched. One common way this can occur is as a consequence of congestive heart failure. In severe cases cirrhosis may occur.

3. Biliary colic: RUQ pain, intermittent, usually begins abruptly and subsides gradually. Attacks often occur after eating. Nausea is common. It is sometimes taught that patients are female, forties, fat and fair although this is obviously a generalization.

4. Acute cholecystitis: Pain similar to biliary colic but more severe and persistent. The pain may radiate to the back or right shoulder. The patient may be pyrexial and Murphy's sign positive (arrest of inspiration on palpation of the RUQ)

5. Ascending cholangitis: An infection of the bile ducts commonly secondary to gallstones. Classically presents with a triad of:
 fever (rigors are common)
 RUQ pain
 jaundice

6. Gallstone ileus: This describes small bowel obstruction secondary to an impacted gallstone. It may develop if a fistula forms between a gangrenous gallbladder and the duodenum. Abdominal pain, distension and vomiting are seen.

7. Cholangiocarcinoma: Persistent biliary colic symptoms, associated with anorexia, jaundice and weight loss. A palpable mass in the right upper quadrant (Courvoisier sign), periumbilical lymphadenopathy (Sister Mary Joseph nodes) and left supraclavicular adenopathy (Virchow node) may be seen.

8. Acute pancreatitis: Usually due to alcohol or gallstones Severe epigastric pain Vomiting is common Examination may reveal tenderness, ileus and low-grade fever Periumbilical discolouration (Cullen's sign) and flank discolouration (Grey-Turner's sign) is described but rare.

9. Pancreatic cancer: Painless jaundice is the classical presentation of pancreatic cancer. However pain is actually a relatively common presenting symptom of pancreatic cancer. Anorexia and weight loss are common.

10. Amoebic liver abscess: Typical symptoms are malaise, anorexia and weight loss. The associated RUQ pain tends to be mild and jaundice is uncommon.