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  #1  
Old 07-11-2012
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Liver RUQ Pain in Alcoholic!

A 50-year-old male with a history of alcoholism presents with severe RUQ pain, nausea, and fever.
Lab: AST 45, ALT 35, alk phos 200, WBC 17,000.
Ultrasound shows 3-4 small gallstones, no pericolic fluid.
What is most likely diagnosis ?

1. acute cholecystitis
2. acute cholangitis
3. pancreatitis
4. acute hepatitis
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2. Acute Cholangitis?
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Old 07-11-2012
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Quote:
Originally Posted by tyagee View Post
A 50-year-old male with a history of alcoholism
presents with severe RUQ pain, nausea, and fever.
Lab: AST 45, ALT 35, alk phos 200, WBC 17,000.
Ultrasound shows 3-4 small gallstones, no pericolic
fluid. what is most likely diagnosis ?

1.acute cholecystitis
2.acute cholangitis
3.pancreatitis
4.acute hepatitis
1.acute cholecystitis

Unlikely to be acute cholangitis since there is no h/o chills and no jaundice.
Nothing to suggest Pancreatitis (pain radiating to back, amylase, lipase etc)
Acute hepatitis should have very high ast/alt

Quote:
None of the ultrasonographic criteria for diagnosing AC (eg, cholelithiasis, thickened GB wall, nonshadowing echoes, sonolucent stripes, pericholecystic fluid) are specific. Differentiating acute cholecystitis from chronic cholecystitis is possible in only 26% of patients. In 74% of patients, therefore, it is not possible to differentiate between acute and chronic cholecystitis on the basis of ultrasonographic findings. AC is presumed to be present if ultrasonography reveals no other apparent cause of abdominal pain.

Last edited by Novobiocin; 07-11-2012 at 07:28 PM.
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acute cholangitis would present with the classic triad of FEVER - PAIN - JAUNDICE.


acute cholecystitis usually presents with FEVER- RUQ PAIN
jaundice if present indicates choledocolithiasis.



also regarding the fluid on USG --
periCHOLECYSTIC fluid --- cholecystitis
periCOLIC fluid --- favors cholangitis



check out this UPENN article just about this topic and how to differentiate between the two.

http://www.med.upenn.edu/gastro/docu...holangitis.pdf
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Old 07-12-2012
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Default my take

sorry but in practice we consider pericolic fluid is specific for cholecysititis

i can quote like a 100 sources which say so ...

http://books.google.co.in/books?id=V...ngitis&f=false

the above link i found when i googled pericolic fluid in cholangitis out of desperation find out if i m wrong and it just shows nothing but pericolic fluid is specific for cholecystitis and cholangitis was just mentioned in the same page as google will find both words together in a page. (and just think of it ... if its around gall bladder isnt it easy to be around transverse colon ..?)


http://emergency.unboundmedicine.com.../Cholecystitis

http://www.wikiradiography.com/page/...mmon+Bile+Duct
in fact the above article shows how we proceed for evaluating an ultrasound for a patient with gallbladders sepsis ...usually when pericolic fluid is commented upon its done so by keeping cholecystitis in mind.


its clearly not hepatitis , seems like the examiner is trying to rule out cholecystitis ...and there is nothing strictly in favour of pancreatitis other than history of alcoholism and presence of gallstones and there is no mention of amylase lipase and other diagnosis clinching features.

please dont get fixated on the charcots triad ... believe me ...of the 10-15 cholangitis cases i saw ...there were patients who presented with fever ... fever plus pain ... another came with jaundice alone ...another came with fever --> found to have ecoli bacteremia ...which then prompted us to investigate UTI and gi tract and then we found dilated CBD and cholangitis ...suffices to say ...all 3 features need not be present to make the diagnosis

my diagnosis would be acute cholangitis
request tyagee to upload his answer, and explanation and also mention the source of question answer and explanation .

sincerely
megamind.
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thanks . wonderful explanation.

i have a query...may be a lame one... do we need triad of "fever+jaundice+RUQpain" to diagnose cholangitis? i mean, is this triad sensitive enough --such that if it is absent, we can safely RULE OUT cholangitis ?

can we get a question in which patient does not have jaundice but still ans be cholangitis ?
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Quote:
Originally Posted by tyagee View Post
thanks . wonderful explanation.

i have a query...may be a lame one... do we need triad of "fever+jaundice+RUQpain" to diagnose cholangitis? i mean, is this triad sensitive enough --such that if it is absent, we can safely RULE OUT cholangitis ?

can we get a question in which patient does not have jaundice but still ans be cholangitis ?
this topic ALWAYS confuses me too.
the whole cholangitis, cholecystitis, choledocholithiasis thing...
but so far.. how many ever uworld questions i have used this thumb rule for... its been true.

even if you open up any surgery book -- "CHARCOTS TRIAD" of fever RUQ and jaundice is considered to be the rule to diagnose this condition.

(or it may be extended to a pentad to include shock and altered mental status --- but these 3 signs are usually mentioned)


also if you think of it logically --- any kind of inflammation in the biliary tree would back up bile and hence cause jaundice.
so i guess for me.. i just keep it simple and stick to the rule -- just for the sake of answering questions. IF this is not present. its not cholangitis.

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Biliary colic>>>>Gall stones, RUQ pain

Acute cholecystitis>>>> Gall stones (except acalculus) RUQ pain, fever

Choledocholithiasis>>>> Gall stones in bile duct, Jaundice

Acute Cholangitis>>>>> Gall stones in bile duct, Jaundice, fever
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