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A26) Epigastric pain and jaundice
Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.
Learning Outcomes
- Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with epigastric pain.
- Review the DDx considerations in a patient with epigastric pain.
- Identify the spectrum of imaging findings in appropriate modalities for evaluating a patient with epigastric pain.
History
A 65-year-old obese male presents to the ED for five days of worsening, constant epigastric pain radiating to the back with nausea and vomiting. He also endorses itching, dark urine, and pale stools. He denies any past medical history, but endorses transient episodes of colicky right upper quadrant abdominal pain after eating greasy foods.
Physical Exam
BP: 120/75, HR 95, RR 19, Temp 36.8C, O2 saturation 95%. General: The patient has scleral icterus and jaundice. Abdomen: Epigastric tenderness.
Labs
WBC: 7 x 109/L (nl: 4.5-11 x 109/L);
Total bilirubin: 6 mg/dL (nl: <1.2 mg/dL);
Direct bilirubin: 5 mg/dL (nl: <0.3 mg/dL);
Alkaline phosphatase: 550 IU/L (nl: 44-147 IU/L);
GGT: 100IU/L (nl: 5-40 IU/L);
Lipase: 1500 U/L (nl: 0-160 U/L);
Amylase: 700 U/L (nl: 40-140 U/L.
Provisional Diagnosis
Select the Dx you believe is most appropriate
The patient most likely has both gallstone pancreatitis (epigastric pain radiating to the back with nausea and vomiting and elevated lipase and amylase) and cholelithiasis (Jaundice, acholic stools, pruritus, and dark urine with direct hyperbilirubinemia, elevated alkaline phosphatase, and GGT) secondary to an obstructing stone (history of cholelithiasis suggested by postprandial abdominal pain). Cholangitis is unlikely considering the patient is afebrile with a normal WBC count.
Well done. You were correct
Potential Acuity
What is your assessment of the likely acuity for this patient?
Well done. You were correct
The patient requires urgent workup.
First Imaging Study
What is the first imaging study you will order?
A CT of the abdomen with contrast can be used to assess for pancreatitis and cholelithiasis.
Well done. You were correct
Pertinent Imaging Observations
Click on the links below to view images from the study, and assess these key findings as best you can.
CT abdomen and pelvis with IV contrast
The pancreas is normal.
There is peripancreatic fat stranding suggesting inflammation and pancreatitis.
There is an obstructing gallstone.
There is an obstructing gallstone at the ampulla of Vater leading to biliary ductal dilatation.
View the full study if you'd like to take a look yourself.
Second Imaging Study
What is the next imaging study you will order?
No further imaging is needed as the diagnosis is confirmed with the abdominal CT.
Well done. You were correct
What is your Diagnosis now that you have seen the imaging results?
The patient’s presentation and imaging are most consistent with both gallstone pancreatitis and cholelithiasis.
Current Acuity
Initially, you selected and we suggested acuity.
Has your concern for this patient changed?
The patient requires urgent workup and management.
Assessment and Plan
Please provide your assessment and plan for this patient
This patient is a 45-year-old male presenting with gallstone pancreatitis and choledocholithiasis. He will be made NPO and given IVF and analgesics. Gastroenterology should be consulted to evaluate for an ERCP. General surgery will also be consulted for evaluation for delayed cholecystectomy to prevent future recurrence if deemed necessary.
Lessons Learned:
- Choledocholithiasis occurring at the Ampulla of Vater can lead to gallstone pancreatitis.
- After endoscopic intervention for and resolution of gallstone pancreatitis, cholecystectomy may be performed to prevent reoccurrence.
- A CT with contrast may be performed, which would reveal an obstructing stone, biliary ductal dilatation, and peripancreatic fat stranding and pancreatic edema secondary to pancreatitis.
Socioeconomic Factors: Women that are obese, had several children, and are in their 40s are at high risk of developing gallstones.
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