Case 6: Summary

Diagnosis:  Acute calculous cholecystitis with choledocholithiasis

Case Summary:

Our patient presented with acute onset right upper quadrant abdominal pain and jaundice. The differential and work up to be considered for this symptom complex is reviewed below. RUQ ultrasound is a quick, non-invasive, and inexpensive modality for testing and recommended as the first diagnostic step. Likelihood of having choledocholithiasis can be assessed based on the predictors described by the ASGE guidelines. MRCP and EUS are more sensitive than RUQ US for detecting hepatobiliary pathology. ERCP is the procedure that enable therapeutic interventions such as clearing the biliary tree of sludge and stones, sampling of any biliary stricture/mass, and biliary drainage. Patients with acute cholecystitis should be treated with antibiotics and planned for cholecystectomy.

Case authored by: Chip Bowman-zamora MD and Bhavana Bhagya Rao MD

References:

1. Choosing Wisely. Images for Suspected Gallstone Disease. https://www.choosingwisely.org/clinician-lists/sages-imaging-for-suspected-gallstone-disease/
2. Narula VK, Fung EC, Overby DW, Richardson W, Stefanidis D; SAGES Guidelines Committee. Clinical spotlight review for the management of choledocholithiasis. Surg Endosc. 2020 Apr;34(4):1482-1491. doi: 10.1007/s00464-020-07462-2. Epub 2020 Feb 24. PMID: 32095952.
3. ASGE Standards of Practice Committee, Buxbaum JL, Abbas Fehmi SM, Sultan S, Fishman DS, Qumseya BJ, Cortessis VK, Schilperoort H, Kysh L, Matsuoka L, Yachimski P, Agrawal D, Gurudu SR, Jamil LH, Jue TL, Khashab MA, Law JK, Lee JK, Naveed M, Sawhney MS, Thosani N, Yang J, Wani SB. ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis. Gastrointest Endosc. 2019 Jun;89(6):1075-1105.e15. doi: 10.1016/j.gie.2018.10.001. Epub 2019 Apr 9. PMID: 30979521.
4. Pisano, M., Allievi, N., Gurusamy, K. et al. 2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis. World J Emerg Surg 15, 61 (2020). https://doi.org/10.1186/s13017-020-00336-x

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Case 6 Index:
Introduction
Physical Exam
Differential Diagnosis
Diagnostic Testing
Management
Hospital Course

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