Acute Abdominal pain In a 56 year Old Woman - Case Study

History
A 56-year-old woman presents to the emergency department complaining of abdominal pain. Twenty-four hours previously she developed a continuous pain in the upper abdomen that has become progressively more severe. The pain radiates into the back. She feels nauseated and alternately hot and cold. Her past medical history is notable for a duodenal ulcer, which was successfully treated with Helicobacter eradication therapy 5 years earlier. She smokes 15 cigarettes a day and shares a bottle of wine each evening with her husband.

Examination
The patient looks unwell and dehydrated. She weighs 115 kg. She is febrile, 38.5°C; her pulse is
108/min, and blood pressure is 124/76 mmHg. Cardiovascular and respiratory system examination
is normal. She is tender in the right upper quadrant and epigastrium, with guarding and rebound tenderness. Bowel sounds are sparse.

Investigations:
Hemoglobin =  14.7 g/dL ( normal = 11.7–15.7 g/dL)
White cell count = 19.8 × 109/L  (normal = 3.5–11.0 × 109/L)
Platelets = 239 × 109/L (normal =  150–440 × 109/L)
Sodium = 137 mmol/L  (normal = 135–145 mmol/L)
Potassium = 4.8 mmol/L  (normal =3.5–5.0 mmol/L
Urea = 8.6 mmol/L  (normal =2.5–6.7 mmol/L)
Creatinine  = 116 μmol/L  (normal =70–120 μmol/L)
Bilirubin = 19 μmol/L  (normal =3–17 μmol/L)
Alkaline phosphatase = 58 IU/L  (normal =30–300 IU/L)
Alanine aminotransferase (AAT) = 67 IU/L  (normal =5–35 IU/L)
Gamma-glutamyl transpeptidase = 72 IU/L  (normal =11–51 IU/L)
C-reactive protein (CRP) = 256 mg/L (normal = <5 mg/L)

A plain abdominal X-ray is shown in picture below

Questions
• What is the most likely diagnosis?
• How would you manage this patient?

Case Discussion


Diagnosis: This woman has acute cholecystitis.

Cholecystitis is most common in obese, middle-aged women and classically is triggered by eating a fatty meal. Cholecystitis is usually caused by a gallstone impacting in the cystic duct. Continued secretion by the gallbladder leads to increased pressure and inflammation of the gallbladder wall. Bacterial infection is usually by Gram-negative organisms and anaerobes. Ischaemia in the distended gallbladder can lead to perforation, causing either generalized peritonitis or formation of a localized
abscess. Alternatively the stone can spontaneously disimpact and the symptoms spontaneously improve. Gallstones can become stuck in the common bile duct, leading to cholangitis or pancreatitis. Rarely, gallstones can perforate through the inflamed gallbladder wall into the small intestine and cause intestinal obstruction (gallstone ileus).

The typical symptom of acute cholecystitis is sudden-onset right upper quadrant abdominal pain that radiates into the back. An episode of prolonged right upper quadrant pain associated with fever, suggests acute cholecystits rather than simple biliary colic. Jaundice usually occurs if there is a stone in the common bile duct.
There is usually fever, tachycardia, guarding and rebound tenderness in the right upper quadrant (Murphy’s sign). In this patient the leucocytosis and raised CRP are consistent with acute cholecystitis. If the serum bilirubin and liver enzymes are very deranged, acute cholangitis due to a stone in the common bile duct should be suspected.

The abdominal X-ray is normal; the majority of gallstones are radiolucent and do not show on plain films.

Differential diagnosis:The major differential diagnoses of acute cholecystitis include

• biliary colic, 
• perforated peptic ulcer, 
• acute pancreatitis, 
• acute hepatitis, 
• subphrenic abscess, 
• retrocaecal appendicitis,
• right pyelonephritis and 
• perforated carcinoma or diverticulum of the hepatic flexure of the colon. 
• Myocardial infarction or right lower lobe pneumonia may also mimic cholecystitis.

Management: This patient should be admitted under the surgical team. Serum amylase should be measured to rule out pancreatitis. Blood cultures should be taken. Chest X-ray should be performed to exclude pneumonia and erect abdominal X-ray to rule out air under the diaphragm, which occurs with a perforated peptic ulcer.

An abdominal ultrasound will show gallstones and inflammation of the gallbladder wall.

The patient should be kept nil by mouth, given intravenous fluids, analgesia and commenced on intravenous cephalosporins and metronidazole.
The patient should be examined regularly for signs of generalized peritonitis or cholangitis.
If the symptoms settle down the patient is normally discharged to be readmitted in a few weeks once the inflammation has settled down to have a cholecystectomy. There is a trend to performing immediate cholecystectomy in low risk patients.