doc_clotaire
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A 39-year-old woman comes to the office because of "spasms" of abdominal pain and nausea over the past few hours. The pain, which is located in the right upper quadrant and radiates to the back, started a little while after she ate french fries at a fast food restaurant with her son. She has had similar episodes of pain in the past. Her temperature is 37.0 C (98.6 F), blood pressure is 120/80 mm Hg, pulse is 75/min, and respirations are 16/min. Physical examination shows mild right upper quadrant tenderness with no rebound or guarding. An ultrasound of the abdomen shows acoustic shadowing of opacities within the gallbladder lumen that change with the patient's position. Laboratory studies show a leukocyte count of 9,000/mm3. The most likely diagnosis is
A. acute acalculous cholecystitis
B. acute calculous cholecystitis
C. acute cholangitis
D. biliary colic
E. primary sclerosing cholangitis
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| Korotkoff
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This should be B.
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| farnsworth
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where are the '-itis' signs?
WBC: normal
Temp: normal
I would call it (D): biliary colic
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| Korotkoff
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Then, what are the opacities seen by ultrasound in the gallbladder?
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| farnsworth
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what you see is sludge or stones (chole-(cysto-)lithiasis), but no signs of infection ("-itis"), like increased WBC, fever, or thickening of the gall bladder wall.
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| lampard
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I have to agree wih farnsworth....
Biliary colic
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| docnikki
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I had chosen calculous cholecystitis but agree with farnsworth 
D.
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| mildus
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I agree that it is biliary colic. Lack of fever, leucocytosis and peritoneal irritation signs wouldn't usually occur with acute cholecystitis
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| aspire
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B ?
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| doc_clotaire
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Explanation:
The correct answer is D.
This patient has biliary colic, which is characterized by crampy, right upper quadrant abdominal pain that may radiate to the back and often follows a meal. Nausea and vomiting may be present. Fever, chills, and leukocytosis are notably absent. Gallstones are present on an ultrasound. The treatment of symptomatic gallstones is usually laparoscopic cholecystectomy.
Acute acalculous cholecystitis (choice A) is characterized by fever, nausea and vomiting, right upper quadrant abdominal pain, and inspiratory arrest on palpation of the right upper quadrant (Murphy's sign). An elevated leukocyte count is usually present. Gallstones are not present and it is usually associated with trauma, burn, surgery, diabetes mellitus, and bacterial infections of the gallbladder.
Acute calculous cholecystitis (choice B) is characterized by fever, nausea and vomiting, right upper quadrant abdominal pain, and inspiratory arrest on palpation of the right upper quadrant (Murphy's sign). An elevated leukocyte count is usually present. It is associated with gallstones.
Acute cholangitis (choice C) is characterized by fever, right upper quadrant pain, and jaundice (Charcot's triad). This patient is afebrile and is not jaundiced.
Primary sclerosing cholangitis (choice E) is a rare disease characterized by inflammation, fibrosis, and strictures within the biliary system. It typically presents with obstructive jaundice, malaise, anorexia, pruritus, and indigestion. It is sometimes associated with ulcerative colitis. This patient's findings are more consistent with biliary colic than sclerosing cholangitis.
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