24 yo F, history of gallstones, presents to the ED with 2 hours of severe, aching RUQ abdominal pain that woke her from sleep. Associated w/ nausea and vomiting. Patient has had similar episodes of pain in the past, often after eating fatty foods.  On exam she is tender in RUQ of abdomen and is actively vomiting.  An US is done.   What is the diagnosis?  Scroll down for answer.

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Answer:  Symptomatic Cholelithiasis

-Characterized by episodes of RUQ pain that are brought on by obstructing gallstone and relieved when gallstone moves from that position

-Can progress to cholecystitis if gallstone remains in obstructing position and gallbladder subsequently becomes inflamed or infected.

-Differential - cholecystitis, choledocholithiasis, cholangitis.

-If simple symptomatic cholelithiasis (no signs of infection or other biliary obstruction) and pain is controlled, patient can often be discharged from ED with outpatient surgical follow-up.

Symptomatic Cholelithiasis vs Cholecystitis on US

Cholecystitis may have

1. Gallstones present in GB
2.  (+) sonographic Murphy’s sign (maximal tenderness over the most anterior portion of GB as defined with US imaging)
3. Wall thickness of gallbladder over 3mm. Be sure to measure GB wall thickness at anterior aspect to avoid false positive increased secondary to posterior acoustic enhancement!
4.   Pericholecystic fluid

 These findings should be used in conjunction with lab results to help identify diagnosis on spectrum of biliary disease.

Resources

Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8th Edition. Ch 79: Pancreatitis and Cholecystitis. Judith E. Tintinalli.

Soni, Nilam, et. al. Point of Care Ultrasound, 2nd Edition. Ch 27: Gallbladder