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* A 44-year-old obese woman
  malak - 11/12/06 13:18
  A 44-year-old obese woman presents to the emergency department complaining of 3 hours of severe abdominal pain. She has also had multiple episodes of vomiting during this time. She describes the pain as "worse than labor," and it radiates to the interscapular region. Her temperature is 38.9 C (102 F), and she has severe tenderness in her right upper quadrant. She reports that she has had multiple similar episodes in the past that have lasted approximately 30 minutes and then resolved spontaneously. Which of the following is most likely being obstructed by a gallstone?

A. Common bile duct

B. Common hepatic duct

C. Cystic duct

D. Pancreatic duct
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* Re:A 44-year-old obese woman
  malak - 11/12/06 15:10
  C. Cystic duct  
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* Re:A 44-year-old obese woman
  dolly123 - 11/12/06 18:58
  how do we deduce this ?  
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* Re:A 44-year-old obese woman
  malak - 11/12/06 19:03

The correct answer is C. This patient with acute cholecystitis has multiple risk factors, including female gender, obesity, and a classic history of prolonged biliary colic in association with fevers. The presentation illustrated is typical and results from obstruction of the cystic duct, which drains the gallbladder.

Obstruction of the common bile duct (choice A) or the pancreatic duct (choice D) will produce acute bacterial cholangitis, which would be demonstrated by Charcot's triad, i.e., right upper quadrant pain, fever, and jaundice. Obstruction of either the common hepatic duct (choice B) or the right hepatic duct (choice E) may give a limited episode of cholangitis but will not cause cholecystitis, since the obstruction occurs in the biliary tree above the level of the entry of the cystic duct.

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