11-27-2007, 11:00 AM
A 44-year-old school bus driver comes to the emergency department complaining of severe
abdominal pain. She reports that the pain began approximately 8 hours ago, after eating lunch
at a fast-food restaurant. The pain has become increasingly severe and radiates to her back.
She recalls a similar episode, lasting 3 hours, 2 months earlier and another episode, lasting 12
hours, during her last pregnancy. She is febrile, with a temperature of 38.1 C (100.5 F), and
has right upper quadrant tenderness with deep palpation of this area. A rectal examination
reveals brown stool that is negative for occult blood. Her leukocyte count is 12,900/mm3, and
her hematocrit is 39%. Her total bilirubin is 2.1 mg/dL. Which of the following is the most
appropriate diagnostic test?
A. CT scan of the abdomen and pelvis
B. Endoscopic retrograde cholangiopancreatography (ERCP)
C. HIDA scan
D. Percutaneous transhepatic cholangiogram (PTC)
E. Upper gastrointestinal barium study
The correct answer is C. This patient has the classic presentation of acute
cholecystitis. The episodes she had several months ago and during pregnancy suggest
a prior history of biliary colic. A HIDA scan is a noninvasive nuclear medicine test that
will reveal obstruction of the cystic duct, which is caused by an impacted gallstone and is
the cause of acute cholecystitis.
A CT scan (choice A) may show a distended gallbladder, but it is not as accurate as a
HIDA scan for evaluating the cystic duct.
Endoscopic retrograde cholangiopancreatography (ERCP) (choice B) is useful for
evaluation of the common bile duct but is of a less value in evaluation of the cystic duct
and, furthermore, is a far more invasive test than a HIDA scan.
Percutaneous transhepatic cholangiography (PTC) (choice D) is an examination that is
performed by the interventional radiologist by injecting the intrahepatic biliary tree
percutaneously. This is rarely done since ERCP is a more accurate evaluation of the
biliary of tree. PTC is of limited value in evaluating the cystic duct and it is an invasive
procedure.
An upper gastrointestinal barium study (choice E) may be useful for the evaluations of
peptic ulcer disease but the symptoms here are far more suggestive of acute
cholecystitis. Furthermore, if the patient has been vomiting she is unlikely to tolerate this
examination.
abdominal pain. She reports that the pain began approximately 8 hours ago, after eating lunch
at a fast-food restaurant. The pain has become increasingly severe and radiates to her back.
She recalls a similar episode, lasting 3 hours, 2 months earlier and another episode, lasting 12
hours, during her last pregnancy. She is febrile, with a temperature of 38.1 C (100.5 F), and
has right upper quadrant tenderness with deep palpation of this area. A rectal examination
reveals brown stool that is negative for occult blood. Her leukocyte count is 12,900/mm3, and
her hematocrit is 39%. Her total bilirubin is 2.1 mg/dL. Which of the following is the most
appropriate diagnostic test?
A. CT scan of the abdomen and pelvis
B. Endoscopic retrograde cholangiopancreatography (ERCP)
C. HIDA scan
D. Percutaneous transhepatic cholangiogram (PTC)
E. Upper gastrointestinal barium study
The correct answer is C. This patient has the classic presentation of acute
cholecystitis. The episodes she had several months ago and during pregnancy suggest
a prior history of biliary colic. A HIDA scan is a noninvasive nuclear medicine test that
will reveal obstruction of the cystic duct, which is caused by an impacted gallstone and is
the cause of acute cholecystitis.
A CT scan (choice A) may show a distended gallbladder, but it is not as accurate as a
HIDA scan for evaluating the cystic duct.
Endoscopic retrograde cholangiopancreatography (ERCP) (choice B) is useful for
evaluation of the common bile duct but is of a less value in evaluation of the cystic duct
and, furthermore, is a far more invasive test than a HIDA scan.
Percutaneous transhepatic cholangiography (PTC) (choice D) is an examination that is
performed by the interventional radiologist by injecting the intrahepatic biliary tree
percutaneously. This is rarely done since ERCP is a more accurate evaluation of the
biliary of tree. PTC is of limited value in evaluating the cystic duct and it is an invasive
procedure.
An upper gastrointestinal barium study (choice E) may be useful for the evaluations of
peptic ulcer disease but the symptoms here are far more suggestive of acute
cholecystitis. Furthermore, if the patient has been vomiting she is unlikely to tolerate this
examination.