Acute Abdominal Pain

History
A 40 year old man presents with pain in the right upper abdomen for 2
days, associated with a swinging fever, nausea and vomiting. No other
symptoms are present.
His medical and drug histories are unremarkable. His history is otherwise
significant only for multiple visits to India during the last one year. The
last visit was around a month ago.
His full blood count shows a leukocyte count of 14,400/mm3, with 91%
neutrophils.

Physical
VS: BP 90/70 HR 120 T 100.1F RR 16 SpO2 97%
General: WM in acute distress clutching his abdomen in pain
HEENT: PERRLA, EOM intact. Sclera slightly icteric. No noticeable or palpable swelling in neck, trachea midline.
No LAD appreciated.
Cardiovascular: RRR no m/r/g, no JVD, no carotid bruits.
Lungs: CTAB, no use of accessory muscles, no crackles , wheezing, or rhonchi.
Skin: signs of jaundice present; no spider angioma or palmer erythema noted
Abdomen: Tenderness in right upper quadrant; no guarding or rigidity
Genital-Urinary: Not performed
Rectal: Not performed
Extremities: No edema, cyanosis or clubbing, and no swollen or erythematous joints.
Neurological: Alert and oriented x 3, CN 2-12grossly intact.

LABS
CBC:
leukocyte count of 14,400/mm3
Left shift with 91% neutrophils.

BMP: unremarkable

Which should be part of diagnostic workup?

A. Amylase + Lipase
B. U/S of abdomen
C. Liver function tests
D. Endoscopic U/S
E. All of the above

Diagnostic Workup?
A. Amylase + Lipase
B. U/S of abdomen
C. Liver function tests
D. Endoscopic U/S
E. All of the above

Results
Amylase + Lipase
Amylase:50 U/L (40 - 140)
Lipase: 45 U/L (30 - 210)

U/S of abdomen
The common bile duct is 1.5 cm in diameter; a hyperechogenic tubular structure without acoustic shadowing is seen
inside. The intrahepatic bile ducts are grossly dilated. The gallbladder is contracted and no gallstones are seen.

Liver function tests

AST: 56 U/L (14 - 59)

ALT: 50 U/L (10 - 55)
ALP: 430 U/L (45 - 150)
Total bilirubin: 5.81 mg/dL (0.3 - 1.0)
Direct bilirubin: 4.88 mg/dL (0.1 - 0.3)

Endoscopic U/S
Roundworms are seen in the 2nd part of the duodenum. The common bile duct and intrahepatic bile ducts are
dilated. A motile tubular structure is seen inside the biliary tree.

Which of the following are part of the DDx?

A. Acute Cholecystititis
B. Acute Cholangitis
C. Diverticulitis
D. Acute Appendicitis
E. Acute choledocholithiasis
F. Acute Pancreatitis
G. Only B,C,D
H. Only A,B,E, and F
I. All of the above

Which of the following are part of the DDx?

A. Acute Cholecystititis
B. Acute Cholangitis
C. Diverticulitis
D. Acute Appendicitis
E. Acute Choledocholithiasis
F. Acute Pancreatitis
G. Only B,C,D
H. Only A,B,E, and F
I. All of the above

Diagnosis
This patient most likely has acute cholangitis.

Fig 2. U/S depicting dilated CBD and

distended GB.
Fig 1. Normal biliary anatomy

What triad supports the Dx?

A. Walters triad
B. Charcots triad
C. Benjamins triad
D. Henrys triad

What triad supports the Dx?

A. Walters triad
B. Charcots triad
C. Benjamins triad
D. Henrys triad

What is Charcots triad and what must you

rule out?
A. RUQ pain, melena, jaundice; need to rule out nephrolithiasis and
choledocholithiasis
B. RUQ pain, melena, jaundice; need to rule out cholelithiasis and
choledocholithiasis
C. RUQ pain, fever, jaundice; need to rule out cholelithiasis and
choledocholithiasis
D. RUQ pain, fever, jaundice; need to rule out nephrolithiasis and
choledocholithiasis

What is Charcots triad and what must you

rule out?
A. RUQ pain, melena, jaundice; need to rule out nephrolithiasis and
choledocholithiasis
B. RUQ pain, melena, jaundice; need to rule out cholelithiasis and
choledocholithiasis
C. RUQ pain, fever, jaundice; need to rule out cholelithiasis and
choledocholithiasis
D. RUQ pain, fever, jaundice; need to rule out nephrolithiasis and
choledocholithiasis

Charcots Triad DDx

Fig 3. Anatomy of extra-hepatic biliary

pathologies.

Management of Acute Cholangitis

Immediate: ABCs, IV fluids, Monitor
vitals and cardiac findings
Long-term:
broad spectrum antibiotics
covering both gram + and gram organisms (e.g.
Imipinem/Meropynem, Zosyn,
Unasyn, etc.)
Eventual decompression of
gallbladder using ERCP or open
surgical intervention

References
Riviello, Ralph J., and William J. Brady. "Presentation and Management of Acute Biliary Tract Disorders in the
Emergency Department Optimizing Assessment and Treatment of Cholelithiasis and Cholecystitis." AHC Media
Continuing Medical Education Publishing RSS. Emergency Medicine Reports, 11 Aug. 2002. Web. 14 Oct. 2016.
Cucchiaro G, Watters CR, Rossitch JC, et al. Deaths from gallstones. Incidence and associated clinical factors.
Ann Surg 1989;209:149.
Gracie WA, Ransohoff DF. The natural history of silent gallstones: The innocent gallstone is not a myth. N Engl J
Med 1982;307:798.
Rosenthal RA, Andersen DK. Surgery in the elderly: Observations on the pathophysiology and treatment of
cholelithiasis. Exp Gerontol 1993;28:459.
Traverso LW. Clinical manifestations and impact of gallstone disease. Am J Surg 1993;165:405.
Warwick DJ, Thompson MH. Six hundred patients with gallstones. Ann R Coll Surg Engl 1992;74:218.
Debray D, Pariente D, Gauthier F, et al. Cholelithiasis in infancy: A study of 40 cases. J Pediatr 1993;122:385.
Grosfeld JL, Rescorla FJ, Skinner MA, et al. The spectrum of biliary tract disorders in infants and children.
Experience with 300 cases. Arch Surg 1994;129:513.

Any questions?