Presentation and evaluation

The evaluation of a patient with right upper quadrant abdominal pain begins with a careful history and physical. Noting the character, location, duration, radiation, and intensity of symptoms as well as aggravating, alleviating, and associated findings will lead to a reasonable differential diagnosis. For example, RUQ pain that is post-prandial, that begins 30 minutes after a meal and lasts for 2 hours, radiates around the back, is dull in nature, and abates spontaneously is most likely biliary colic due to gallstones.

Symptoms associated with acute cholecystitis are usually more acute and persistent. The patient may have a history of biliary colic, with the pain starting in the epigastrium, associated bloating or belching. Subsequently, the pain may worsen and radiate to the right upper quadrant. Patients may confuse these symptoms with heartburn. Pertinent history can include use of antacids without relief of symptoms. There also may be an associated fever. On palpation of the RUQ a premature inspiratory pause may be noted (Murphy’s sign). A palpable gallbladder with jaundice may indicate chronic bile duct obstruction from tumor and may not have much associated pain (painless jaundice). Occasionally a point of maximal tenderness may be in the RLQ or more epigastric depending on the anatomy of the patient. An elevated pulse rate or temperature may also go along with acute cholecystitis.

Laboratory studies to assist in narrowing the differential diagnosis will include a CBC, chem 20 including an AST, ALT, bilirubin, alkaline phosphatase, amylase, and urinalysis. A chest x-ray may also be helpful in identifying lower lobe pneumonia or finding free air under the diaphragm. An elevated WBC, increased temperature, and RUQ tenderness may indicate cholangitis (purulent fluid/pus in common bile duct). This will necessitate urgent antibiotics and possible early bile duct decompression by a surgical or endoscopic means. There may be some mild liver function test elevations and a significant alkaline phosphatase elevation. An elevated amylase suggests pancreatitis; etiology may be idiopathic or from gallstones, alcohol, or drug use. An elevated WBC and persistent RUQ pain and/or tenderness with normal LFT’s usually leads to the diagnosis of acute cholecystitis. An ultrasound can be helpful in the diagnostic work up because it may show gallbladder wall thickening or pericholecystic fluid. The nuclear medicine HIDA scan is most definitive test to confirm acute cholecystitis.

The initial treatment of acute cholecystitis involves keeping the patient NPO, IV antibiotics and fluid replacement. If the diagnosis can be made with confidence or confirmed with another study, parenteral narcotics may be used for pain control. Meperidine is preferred over morphine because it tends to cause less sphincter of Oddi contraction. Monitor vital signs and urine output. Patients begin to notice an improvement within a few hours and are significantly better in 12-18 hours. Patients that look worse and have an increasing WBC should be re-evaluated for other possible causes or a failure of initial non-operative management. Consider as an urgent Medevac for early surgical care. The majority of acute cholecystitis patients will respond to IV antibiotics. Cholecystectomy can be delayed 24-72 hours. If this is not available, initial non-operative treatment with 5-7 days of antibiotic therapy followed by elective cholecystectomy in 6 weeks is acceptable, although there is a 10-20 percent recurrence rate of symptoms in the convalescence period.

Initial treatment of pancreatitis should include placing the patient in a NPO status, establishment of IV hydration, and nasogastric tube suctioning for multiple episodes of emesis or evidence of an ileus on abdominal x-rays. Patients should respond in 12 hours. Intravenous Meperidine may be used sparingly to get initial pain control. Therapy should be continued until pain, ileus, and hyperamylasemia resolve.

On admission

• Age >55

• WBC > 15,000/mm³

• Blood Glucose > 200mg/dl

• Lactate dehydrogenase > 350 IU/L

• Aspartate transaminase >250 U/L

Within 48 hours

• BUN >5mg/dl

• Pa02 <60mmHg

• Serum calcium <8mg/dl

• Decrease in HCT >10%

• Base deficit >4mEq/L

• Fluid sequestration > 6L

Patients with more than 2 of Ranson’s criteria should be considered for early medevac as well as patients that get progressively worse or have significant ileus.

Acute cholangitis can be initially managed with IV antibiotics (usually a second or third generation cephalosporin to cover predominantly gram negative organisms). The patient should be evaluated further to determine the etiology of the cholangitis (i.e., choledocholithiasis). This may be done with a variety of tools including ultrasound, ERCP, and/or CT scanning. Any patient with acute cholangitis that deteriorates or does not rapidly respond to antibiotic therapy should be evacuated as soon as safely possible.

Reference

1. Sabiston DC, Textbook of Surgery, 15^th edition, p. 1161.