Transcript A Lady with Right Upper Quadrant Pain

HKCEM College Tutorial
A Lady with
Right Upper
Quadrant Pain
AUTHOR
DR. LEE KF, DR. TANG CO, DR. TAM MK
REVISED BY
DR CHAN CHI MING
MAY 2013
Triage Notes
▪ F/75
▪ c/o: RUQ pain for 1 day
▪ PMH: DM, IHD, old PTB
▪ BP 172/78
▪ P 96/min
▪ T 37.8 ºC
Triage Cat III
What are your differential diagnosis ?
▪ Cholecystitis
▪ Cholangitis
▪ Liver abscess
▪ PPU
▪ Basal pneumonia
▪ AMI…
What would you like to ask in the history ?
History
▪ Pain = PQRST
▪ Place
RUQ
▪ Quality
constant
▪ Radiate to scapula
▪ Severity e.g. pain score
▪ Time
for one day
▪ Fever & system review
▪ CVS
ischemia
▪ Resp
cough…
▪ GU
renal colic
▪ PMH
▪ GI symptoms
▪ N, V, D,
▪ Jaundice, tea color urine
▪ Current med
▪ Drug allergy
Physical Findings
▪ A fat lady with T 37.8°C
▪ No pallor or jaundice
▪ A palpable globular shape mass at RUQ of abdomen
▪ Murphy’s sign positive
▪ Other systems essentially normal
What is Murphy’s sign ?
▪ Murphy’s sign is a reliable sign of acute
cholecystitis
▪ The patient is asked to take a deep breath while the examiner
palpates the gallbladder region
▪ The breath catches at the zenith of inspiration as the inflamed
gallbladder moves down into contact with the examining hand
▪ Elicit tenderness  Positive
Demonstration
What is Courvoisier’s law ?
▪ Courvoisier’s law states that
▪ if the gallbladder is palpable in the presence
of jaundice, the jaundice is unlikely to be due
to stone
What is Charcot’s triad ?
= RUQ pain + pyrexia + jaundice
▪ It suggests a diagnosis of cholangitis
What is the differential diagnosis of RUQ mass ?
• Gallbladder
• Liver
• Colon
What is the differential
diagnosis for this lady ?
X-ray
Blood
ECG
Ultrasound
Progress
What
investigations
would you order ?
What are the findings ?
• Clear lung fields
• No free gas
X-ray
• RUQ opacity likely gallstone
• No pneumobilia
• No dilated bowel
X-ray
CXR (erect film)
▪ to look for free gas under diaphragm, which may be caused by
PPU or perforated gallbladder in case of acute cholecystitis
AXR
▪ to look for calcified lesion suggesting gallstone
▪ Also look for sign of IO (gall stone ileus in case of acute
cholecystitis)
Gallstone
▪ Only 15% of stones contain enough calcium to be seen on a plain film
▪ Ultrasound is a much more sensitive test for gallstone
Blood
CBC
LFT
▪ Hb
12 g/dL
▪ Bili
12 umol/L
▪ WCC
12 x10^9 /L
▪ ALT
57 U/L
▪ ALP
40 U/L
Amylase
89 U/L
< 0.03 mmol/L
RFT
▪ Urea
6.2 mmol/L
Tn-I
▪ Cr
76 umol/L
Glucose / H’stix
13.7 mmol/L
ECG
AF with ventricular rate of about 90/min
no acute ischemic changes
What are the findings ?
Distended
Gallbladder
Gallstone with
echogenic foci &
posterior acoustic
shadow
Ultrasound
Thickened GB wall &
peri-cholecystic fluid
Ultrasound
What are the findings ?
▪ Echogenic foci with posterior acoustic shadowing suggesting gallstones
▪ Distended gallbladder
Compatible with acute cholecystitis
▪ Gallbladder wall thickened
▪ Peri-cholecystic fluid
▪ Positive sonographic Murphy’s sign
▪ Not demonstrate in the picture
Also look for:
- Ductal dilatation (CBD & intrahepatic)
to exclude cholangitis
- Liver tumor as hepatitis B is prevalent
in our locality
- Sub-hepatic fluid collection (abscess)
US demonstration
Ultrasound
▪ What is positive sonographic Murphy’s sign?
Positive sonographic Murphy’s sign —
tenderness elicited by pressing the
gallbladder with the US probe
▪ What are the sonographic diagnostic criteria for acute cholecystitis?
What are the sonographic diagnostic criteria for
acute cholecystitis ?
Major diagnostic criteria:
Minor criteria:
▪ Positive sonographic Murphy’s sign
▪ Distended gallbladder
▪ Loss of definition of gallbladder margins
▪ Presence of calculi or sludge
▪ Thickening of the gallbladder wall > 3 mm
(If patient does not have ascites, chronic
liver disease & right heart failure)
▪ Linear or irregular hypoechoic areas
within the wall
▪ Peri-cholecystic fluid
(Indicative of impending perforation)
▪ Intramural gas
Details
(5% of cases are not associated
with gallstones)
Progress
Treatment
▪ Resuscitate if necessary
▪ Analgesia
▪ Admit to surgical unit for further management
Progress
Treatment after admission
Progress
▪ Confirm the diagnosis by blood tests, formal USG (by radiologist)
▪ Conservative treatment (include: NPO, IV fluid, antibiotics, NG suction if
appropriate)
▪ 90% of cases will settle
▪ Close monitor for complications:
▪ sepsis, empyema, gangrene & perforation
▪ Surgical treatment
▪ laparoscopic or open cholecystectomy
▪ If medically not fit for GA, may perform percutaneous cholecystostomy
The End
ANY QUESTIONS ?