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Old 06-04-2012
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Question most appropriate next step - acute abdomen with scleral icterus !!!

A 52-year-old woman is evaluated in the emergency department for acute abdominal pain of 8 hours' duration. She has had 3 to 4 weeks of intermittent, sharp right upper quadrant abdominal pain lasting 30 minutes to 1 hour occasionally associated with nausea but not with fever or diarrhea. The pain is precipitated by meals. Last night after dinner the pain recurred and has persisted despite treatment with acetaminophen. She is otherwise healthy, has never had surgery, and takes no other medications.

On physical examination, she is overweight (BMI 28) and appears uncomfortable. Temperature is 38.1 C (100.5 F), blood pressure is 122/68 mm Hg, and heart rate is 76/min. There is scleral icterus. Bowel sounds are normal; there is right upper quadrant abdominal tenderness to palpation, particularly with inspiration, but no masses.

Laboratory Studies
Leukocyte count

12,400/L
Aspartate aminotransferase

12 U/l
Alanine aminotransferase

18 U/L
Alkaline phosphatase

218 U/L
Total bilirubin

2.6 mg/dL

Which of the following is the most appropriate next step in the management of this patient?

A Abdominal ultrasonography
B CT scan of the abdomen
C Endoscopic retrograde cholangiopancreatography (ERCP)
D Low-fat diet and diclofenac
E Magnetic resonance cholangiopancreatography (MRCP)
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Old 06-04-2012
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A, abd US is the best initial when suspect cholecystitis. and there's also associated elevation of Bil, so US will help delineate biliary tree (though it can be Mirizzi's syndrome: a rare complication in which a gallstone becomes impacted in the cystic duct or neck of the gallbladder causing compression of the CBD (common bile duct), resulting in CBD obstruction and jaundice.)
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Old 06-04-2012
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A Abdominal ultrasonography
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A Abdominal ultrasonography
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Old 06-05-2012
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ans is ABD usg.


another query, is this cholangitis [ because of scleral icterus and raised brb ] or is this cholecystitis ?
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Quote:
Originally Posted by tyagee View Post
ans is ABD usg.


another query, is this cholangitis [ because of scleral icterus and raised brb ] or is this cholecystitis ?
Neither.
Cholangitis will have high fever with chills & rigor.
This is choledocholithiasis i.e. gall stone in CBD. That's why the Alk Phos is raised (obstructive jaundice). Next step after USG is ERCP & sphincterotomy with stone extraction using a basket. Sometimes the stone(s) pass spontaneously and that's why you need USG first to see the status of CBD (dilation) and the stone.
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